When she thinks back, Matthea Little Smith realizes she has experienced depression off and on for more than 40 years. Smith, 58, first heard about the symptoms of depression from a teacher when she was in high school-and recognized herself in the description. "I thought, that sounds like me," Smith said. "I had those symptoms. I also thought, aw, it's not a big deal. And it wasn't-until I was about 38."

Smith, who went through menopause at an early age, experienced a severe and lingering clinical depression. "I was pre-menopausal at 38," she said, "And I literally felt like I was going crazy. I couldn't concentrate, I really didn't want to talk to people at all. I was raising six kids, and I used them as an excuse not to be involved in things I'd previously enjoyed, like the statewide PTA. I made excuses: I was tired, I didn't feel well. They were true, too. [In the morning], I was exhausted, I didn't feel like I'd slept."

Smith's teenage depression is not unusual; neither are the depressions she experienced before, during and after menopause. While young boys and girls become depressed at about the same rate, girls and women experience depression at a much higher rate than their male counterparts. The rate of depression among girls begins to climb upward at age 11, by the time a girl is 15, she is twice as likely to be depressed as a boy of the same age. That tendency remains constant throughout a woman's life.

Depression tends to run in families. Women who experience significant stress, have a history of abuse, or live in poverty are at risk. Biological causes are at the top of the list. Most experts agree with Sue Abderholden, executive director of the National Alliance on Mental Illness-Minnesota (NAMI-MN). "Hormones play a huge role," Abderholden said.

The role of hormones
According to Nancy Raymond, M.D., director of the Deborah E. Powell Center for Women's Health and a professor of psychiatry at the University of Minnesota Medical School, hormones are a logical explanation for the higher levels of depression in women. She said scientists need to learn more about how hormones affect brain chemistry. "We do know that radical changes in estrogen are present in all women with PMDD [Premenstrual Dysphoric Disorder, the most severe form of PMS], postpartum depression, and [menopause-related] depression." Raymond said that women are at risk for menopause-related depression for five years before and five years after menopause. Those women who already are depressed will be more affected by these radical changes in hormone levels.

"The data shows, if you're a woman who's tended to have difficult PMS or PMDD you may have a harder time with perimenopausal depression," Raymond said. PMS affects up to 40 percent of all women. About 2 to 10 percent of women have PMDD, the most severe form of PMS. Women with PMDD find the condition significantly disrupts their lives.

About 10 percent of women are depressed during pregnancy. Post-partum mood symptoms are very common: It is estimated that 80 percent of women experience the "baby blues" for a brief time, and about 15 percent of women experience a clinical depression after giving birth. A woman who has a history of depression or another mood disorder is three times as likely to depressed during her pregnancy or post-partum.

Postpartum depression is very different than postpartum psychosis, an extremely rare condition that may lead a woman to harm herself or her child. Only one in a thousand women experience postpartum psychosis.

One of the major risk factors for depression is a history of depression. According to NAMI, 60 percent of women who experience a serious depression have at least one recurrence; 75 to 80 percent whose depression has recurred will have another recurrence. Untreated depression is even more likely to recur. "Severe depressions can cause brain abnormalities that cannot be corrected-patterns of connections, nerves, nervous systems. The brain has complex wiring," Raymond said.

Getting help
The treatment for depression varies according to the individual woman's needs, symptoms, and severity of symptoms. Common treatment options include one or more of the following: psychotherapy, medication, light therapy (SAD), improved diet and exercise, and alternative modalities such as mindfulness training, meditation and acupuncture. In severe cases where other treatments have failed, electroconvulsive therapy (ECT), sometimes called shock therapy, may be prescribed. Though depression treatments are overwhelmingly successful, "the statistics are that people live with symptoms for an average of 10 years before seeking help," Abderholden said.

That statistic comes as no surprise to Mary Bradmiller, Ph.D., who treats mentally ill immigrant women at Hennepin County Medical Center (HCMC). Bradmiller said that while many white professional women may not feel stigmatized by taking an anti-depressant, it's very different for many of her patients, who feel shamed by their illness. "They think of mental illness as a weakness, that they should be able to feel better on their own," Bradmiller said.

Smith, who is African American, understands those feelings. She said she waited "five or six" years before agreeing to take medication for her depression. "We don't talk about depression, about mental illness, in the African-American community or in my family," Smith said. "It is really, really important that we address mental illness in the African-American community like we address diabetes or heart disease. Depression is killing many of our young folks."

There are striking differences in the rate of depression among women when it's broken down by race. Among middle-aged women, 43 percent of Hispanic women have symptoms of depression. For middle-aged African-American women, the rate falls to 27 percent. Twenty-two percent of white American women have depression symptoms, and the percent of Asian-American women with depression symptoms is the lowest among all middle-aged women at 14 percent. But don't take that to mean that all Asian-American women experience a low incidence of depression; adolescent girls and young Asian-American women (aged 15 to 24 years old) have the highest rate of depression of any women.

When she was at her most depressed, Smith considered suicide. "I didn't have a plan," she said, "But I thought about it. It was one of the scariest feelings. I had never understood how people did it, but I was so depressed that I was single-focused. All I saw was myself in this tunnel. The hopelessness is very, very difficult to explain. I got to the point that I really didn't see any reason to be around.

"Thankfully, when I got to that point, one of my children came literally knocking on my door. I looked into her face and I knew, that's the reason I need to be alive-my children would suffer so much if I wasn't here.

"I never want to feel that way again. That is why I take medication. I hadn't experienced that before or since, and I refuse to. I was really lucky she knocked on the door when she did."

Emerging from the tunnel
After that episode, Smith sought treatment. "I can't tell you how helpful the therapy was. I went for three or four years. I learned how to recognize [depressed] behavior. I take a medication that works pretty well. I have a chronic illness that requires me to take care of myself.

"Exercising and eating well helps. I take Vitamin E. I feel like a person with a chronic illness must feel; I take these pills and I take care of myself.

"Recovery wasn't instant. I started getting up earlier. I was comfortable doing my routine. There were a stack of books I wanted to read. I was reading, reading, reading, which I couldn't do before because I couldn't concentrate. It dawned on me that I was focusing."

Smith is the first to say that not every day is perfect. "Some days I wake up tired and cranky," she noted. But she is thriving in her new job as African-American Outreach Director for NAMI-Minnesota. She sees friends and family, which includes three great-grandchildren, instead of isolating herself.

Recently, her recovery was tested when she learned an old friend was dying. "Had I not been in recovery, I wouldn't have gone to see her, I would have gone home and stayed in bed for a week. I saw her and I was sad but I wasn't depressed.

"I am enjoying life. I like being around. It's pretty cool."


Types of depression
There are a number of types of depression. Most of them have the same basic symptoms, including sleep disturbances, loss of energy, difficulty concentrating, sadness, irritability, feelings of hopelessness. The severity of symptoms can vary depending on the type of depression.

• Major depressive disorder, "clinical depression," interferes with a woman's ability to perform normally. Sadness, irritability and lack of interest in everyday activities are common symptoms. Some depressed women experience only one major depression, but most experience several over their lifetime.

• Dysthymia is a chronic depression that lasts for two years or more.

• Bipolar disorder consists periods of depression (generally severe) that alternate with periods of euphoria (mania). Women with bipolar disorder tend to experience more severe depressive episodes than men.

• Seasonal Affective Disorder (SAD) occurs yearly beginning in autumn, as the amount of sunlight decreases, and ending in spring, as the days lengthen.

Is she suicidal?
Signs someone is contemplating suicide include:

• Talking about it. Saying that she wishes she were dead; frequent discussions that center on death or violence

• Preparing to do it. Hoarding pills or buying a gun, etc.

• Withdrawing. Increasingly wanting to be left alone

• Dramatic mood swings

• Increased risky behavior, including escalating use of drugs and alcohol use

• Saying things are hopeless and will never improve

• Getting her affairs in order, giving away possessions, saying goodbye in a final way

Who's at risk?
Along with the hormonal factors that increase a woman's chances of becoming depressed, other risk factors for depression. They include:

• Genetics. Recent studies of twins and first-line relatives of people with depression have shown what doctors long expected-depression runs in families.

• Psychosocial factors. Financial problems, poverty, loss, life changes, physical illness, drug and alcohol abuse and other stress factors put a woman at significant risk.

• History of abuse, rape, and/or sexual harassment can lead to low self-esteem, isolation, and feelings of powerlessness, which may lead to depression.

How to support a depressed loved one
Sometimes it's easier to see depression in someone else than it is for the depressed person to recognize her own symptoms. If you think someone close to you is depressed, you can help by:

• Talking to her about what you've noticed and sharing your concerns

• Asking her to see her physician or a mental health professional

• Suggesting that the person see a mental health provider or his or her doctor

• Explaining that depression is a medical condition that often responds to treatment

• Telling her that there are other conditions that mimic depression and should be checked out by a doctor

• Offering to make the first appointment and to accompany her

• Expressing your willingness to help in any way possible

If your loved one talks about death or threatens suicide, take it seriously. You may need to take immediate action to get help if this occurs.