Depression: symptoms, types and treatment by video in Puerto Rico

Depression is more than feeling sad for a few days. According to the National Institute of Mental Health (NIMH), it is a mood disorder that causes severe symptoms and changes how you feel, think and handle daily activities: work, school, sleep, eating. It can affect anyone, at any age.

It is not weakness or a lack of willpower. Genetics, biology, environment and what you are going through, such as a loss, stress or an illness, all play a part. And it is treatable: most people get better with psychotherapy, medicine or both.

According to the NIMH, depression is considered when several of these signs of depression are present most of the day, nearly every day, for at least 2 weeks:

• A sad, anxious or empty mood that does not go away
• Loss of interest or pleasure in things you used to enjoy
• Hopelessness, guilt or feeling worthless
• Irritability, frustration or restlessness
• Fatigue, low energy or feeling slowed down
• Trouble concentrating, remembering or making decisions
• Trouble sleeping, waking too early or oversleeping
• Changes in appetite or unplanned weight changes
• Aches, headaches or digestive problems without a clear cause
• Thoughts of death or suicide

The NIMH describes several types of depression:

• Major depression: depressed mood or loss of interest most of the time for at least 2 weeks, with symptoms that interfere with daily life.
• Persistent depressive disorder (dysthymia): milder symptoms that last much longer, usually at least 2 years.
• Perinatal and postpartum depression: starts during pregnancy or after childbirth. It is more than the passing "baby blues". If it happens to you, tell the doctor and also your OB-GYN at your next follow-up.
• Seasonal affective disorder: comes and goes with the seasons; symptoms usually start in late fall and early winter.
• Depression with psychosis: a severe form in which a person sees or hears things that are not there or believes things that are not true. It needs urgent care.

Ongoing fatigue is a common symptom of depression, but it does not always come from mood. The NIMH notes that some medical conditions, such as thyroid disorders, and some medicines can cause the same symptoms as depression.

So the doctor looks for the cause. If needed, we give you a lab order for a lab near you, for example to check your thyroid, vitamin B12 (according to the NIH, low B12 can cause depression, confusion and memory problems) or anemia, which also drains your energy. If we find a medical cause, we treat it.

You see Dr. Diana Nieves Castro, a Puerto Rico–licensed general practice physician with several years of emergency-department experience, in English or Spanish. We evaluate, diagnose and treat: the doctor asks how you have been feeling, since when, how you sleep and eat, what medicines or substances you use and whether you have had thoughts of harming yourself. Asking is part of caring for you.

She uses validated questionnaires such as the PHQ-2 and PHQ-9, which measure which symptoms you have and how strong they are, and help track your progress over time.

Screening is part of primary care: the U.S. Preventive Services Task Force (USPSTF) recommends screening all adults for depression, including pregnant and postpartum people and adults 65 and older (2023), and adolescents ages 12 to 18 (2022).

Psychotherapy. Talking with a mental health professional, for example in cognitive behavioral therapy, helps change patterns of thinking and behavior. If it suits you, we refer you.

Activity and routine. Moving a little every day, spending time with people you trust, setting small goals and not isolating yourself all help treatment work. Sleep matters too: if insomnia is part of the problem, we treat it along with your mood.

Antidepressants. These medicines help improve mood. The most widely used are selective serotonin reuptake inhibitors (SSRIs), such as sertraline, escitalopram, citalopram and fluoxetine. Others work differently, such as the SNRIs duloxetine and venlafaxine, bupropion, mirtazapine and trazodone. No single one is best for everyone: the choice depends on your symptoms, your other conditions and the medicines you already take.

What to know about antidepressants: - According to the NIMH, they usually take 4 to 8 weeks to work fully. Sleep, appetite and concentration sometimes improve before mood does. - Do not stop them suddenly. Stopping abruptly can cause dizziness, nausea, sweating, mood changes or sleep problems; if they need to be stopped, the dose is lowered gradually with your doctor. - All antidepressants carry an FDA boxed warning: in short-term studies, they increased the risk of suicidal thoughts and behaviors in children, teens and young adults under 25. Close follow-up matters, especially in the first months and whenever the dose changes.

After evaluating you, the doctor decides which treatment is appropriate and safe for you. If appropriate, the doctor prescribes and we send your prescription to your pharmacy. We never promise a medicine: sometimes the best start is therapy, and sometimes both.

In teens, depression often looks like irritability, falling grades, withdrawal or sleep changes more than sadness. The USPSTF recommends depression screening for ages 12 to 18. The doctor sees patients of all ages by video; patients under 21 need a parent or legal guardian on camera for the whole visit, with ID. If your teen starts an antidepressant, watch for changes in mood or behavior, especially in the first months.

If you are having thoughts of harming yourself or ending your life, you are not alone and help is available right now:

• Línea PAS (ASSMCA): call 1-800-981-0023. It is confidential, free and answers 24 hours a day.
• 988: call or text 988, the Suicide & Crisis Lifeline. Help is available in English and Spanish.
• Emergency: if you are in danger now or have already hurt yourself, call 911 or go to the nearest emergency room.

If you are worried about someone else, stay with them, move weapons and medicines out of reach and call Línea PAS or 988 together. See when to go to the ER.

Book an evaluation; the doctor decides whether a treatment is right for you. See how online mental health care works.

Video doctor visits 24/7: book a visit, talk with the doctor from your phone, tablet or computer and get your plan. We send you a secure video link. You pay by card when you request the visit, with no membership, and we do not bill insurance; see prices. The service is run by The Health Initiative, a nonprofit.