Understanding depression

Depression is more than just about the blues! It is not a weakness, but a mental disorder that needs treatment.

Everyone may feel sad or low mood from time to time. However, if such a feeling lingers for a long period of time without getting better, then the person may be suffering from depression. Depression can affect the way a person eats, sleeps, behaves, feels about oneself, and thinks about things. It can lead to many emotional and physical problems, and it can affect the person’s day-to-day activities. Therefore, it is important to seek help to alleviate depression.

Depression is more common that many people may think of:

350 million people globally are affected by depression [1].
5.8% of of adults in Singapore have depression over their lifetime;
7.2% of women and 4.3% of men are affected. [2]

Depression and Brain Functions

PET scans of the brain showing different activity levels in a person with depression, compared to a person without depression. (Source: Mayo Foundation for Education and Research [4])
PET scans of the brain showing different activity levels in a person with depression, compared to a person without depression.
(Source: Mayo Foundation for Education and Research [4])

Areas of the brain involved [3]:
A depressed person shows higher activity in the amygdala, which is associated with emotions such as anger, pleasure, sorrow, fear, and sexual arousal. The hippocampus, which is involved in learning, memory, and emotion, is smaller than normal in some people with depression. The thalamus is the sensory relay centre of the brain; depression affects the thalamus in linking sensory input to pleasant and unpleasant feelings. When these areas are affected, the ability of the brain to regulate mood goes awry!

Neurotransmitter Imbalance:
Brain cells (neurons) communicate through chemicals called neurotransmitters. In normal brain function, neurotransmitters jump from one neuron to the next, sending strong signal from one neuron to another without degradation. However, in people who are depressed, the mood regulating neurotransmitters fail to function normally, so that the signal is either depleted or disrupted before passing to the next neuron. Serotonin, noradrenaline, dopamine, and Gamma-aminobutyric acid (GABA) are mood regulating neurotransmitters that can be affected [3].

Causes of Depression

Neurotransmitter imbalance plays a role in causing depression.
Neurotransmitter imbalance plays a role in causing depression.

There is no one single cause for depression. Changes in brain function and neurotransmitter imbalance are normally preceded by a combination of other factors that lead to depression. Major factors may include stressful life events (e.g. financial distress, child abuse, relationship problems, death of a spouse, etc.); chronic medical conditions (e.g. IBS, Parkinson’s disease, cancer,etc.); Inheritable genetic factors; Hormonal imbalance (e.g. PMS, peri-menopause and post-natal); side-effects of certain medications (e.g. systemic corticosteroids, oral contraceptive pill, antihypertensive); drug abuse; nutrition deficiency; allergy; and heavy metal toxicity.

Signs and Symptoms

Major depression is diagnosed if a patient has five of the following symptoms for more than two weeks [3]:

  1. Depressed mood
  2. Loss of interest or pleasure
  3. Significant appetite or weight loss or gain
  4. Insomnia or hypersomnia
  5. Psychomotor agitation or retardation
  6. Fatigue or loss of energy
  7. Feelings of worthlessness or excessive guilt
  8. Impaired thinking or concentration; indecisiveness
  9. Suicidal thoughts/thoughts of death.

Depression Types

Depression is a type of mood disorders. There are three major categories of mood disorders:

  • Major depression
  • Bipolar disorder
  • Dysthymia

Major depression is the classic form of depression discussed in this brochure. It can be further classified in term of intensity into Mild, Moderate, ad Severe. Bipolar disorder is a mood disorder characterised by the depressive person also experiencing unusually active and energetic periods (manic episodes). Dysthymia refers a low-level drone of depression that is not as crippling as a major depression, which lasts for at least two years in adults or one year in children and teens.

Treatment Options


Antidepressant medications are the first choice in treatment by medical doctors, especially for one who is experiencing a severe depression or suicidal urges. About 65% to 85% of people get some relief from antidepressants[3]. Selective serotonin reuptake inhibitors (SSRIs) are the most commonly prescribed antidepressants. SSRIs work by slowing the re-absorption of serotonin by the neurons that released it. This allows the serotonin to work for a longer time. SSRIs also appear to change the number and sensitivity of receptors and to indirectly influence other neuro-transmitters, including norepinephrine and dopamine. Other antidepressant medications include: SNRIs, NDRIs, Atypical antidepressants, Tricyclic antidepressants, and MAOIs. However, antidepressants are known to cause side-effects, including sexual difficulties, nausea, insomnia, headaches, and even increase suicidal thoughts.


A combination of all these treatment options is the most effective way to combat depression and prevent relapse
A combination of all these treatment options is the most effective way to combat depression and prevent relapse

Psychotherapy involves talking about one’s condition and related issues with a mental health professional. The aim of psychotherapy is to relieve the patient’s symptoms and to help him/her manage problems better and live a healthier, more satisfying life. By encouraging more constructive ways of thinking and acting, psychotherapy can help to reduce the chance of relapse of depression.

Cognitive behavioural therapy, interpersonal therapy, and psychodynamic therapy are the primary therapies for treating depression. Psychotherapy applies not only for the patient, but also for others close to the patient. Group, family, or couples therapy may also be part of a plan for treating depression Some types of therapy are used together with more established types of psychotherapy, which include behavioural activation therapy, creative arts therapy, and animal assisted therapy.

Self Help Techniques

Generally, professional treatment of depression is required. However, there are a number of self-help techniques that can help to assist the treatment plan and improve its effectiveness.
Here are some of the ways:

  • Eat a healthy, whole food, diet, that is rich in olive oil, fish, fruits and vegetables, nuts, and legumes
  • Exercise for at least 30min a day and 5 times a week
  • Avoid alcohol and recreational drugs
  • Learn to relax – listening to music, go for a walk, take a hot bath, yoga, massage, breathing exercise, etc.
  • Practise mindfulness meditation: focusing attention on what is happening in the present – and accepting it without judgement.
  • Learn expressive writing, involves writing about thoughts and feelings that arise from a traumatic or stressful life experience

Nutrients and Herbs

Peelbark St. Johns-wort (Hypericum fasciculatum) (6439017119)
St. John’s Wort (Hypericum fasciculatum) can be used to treat mild to moderate depression
There are many nutritional supplements and herbal remedies that are safe and effective in addressing depression. Vitamin B complex is important for normalisation of the nerve function. Amino acid derivatives, including N-acetyl cysteine, 5 Hydroxy-Tryptophan (5-HTP), and S-adenosyl-L-methionine (SAMe) can be used to improve mood and sleep. Omega-3 fatty acids, has been used as a stand-alone treatment option for people concerned about side effects of antidepressants, such as the elderly. Magnesium is an important mineral that is required for the regulation of various neurotransmitters.

Herbal remedies can be used to stabilise mood, restore nervous system function, and improve stress response. St John’s Wort, Lavender, Lemon Balm, Damiana, Vervain, and Ginkgo biloba are some commonly used herbs. However, it is important to consult a qualified naturopath/herbalist before taking any of these herbs. Some herbs may have contraindications with antidepressant medication.

Where to get help in Singapore

Here are some places you can start to look for help if yourself or someone you know is affected by depression:

  • Contact your doctor, counsellor, natural medicine practitioner, or local support group
  • Health Promotion Board Health Line: 1800 223 1313 (http://www.hpb.gov.sg/)
  • Samaritans of Singapore (SOS): 1800 221 4444 (http://sos.org.sg)
  • Care Corner (Mandarin): 1800 353 5800 (http:// http://www.carecorner.org.sg/)

A detail list is available at Singapore Psychiatry Association website at http://www.singaporepsychiatry.org.sg/seek-help-to-depression/


  1. World Health Organization (2012) Depression. Fact sheet No. 369. Oct 2012
  2. Chong, S.A. et al (2012). A Population-based Survey of Mental Disorders in Singapore, Ann Acad Med Singapore, 41:49-66
  3. Harvard Medical School (2013). Understanding Depression. Harvard Health Publications, USA
  4. Mayo Clinic (2014). Depression (major depressive disorder)

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