About Depression

What is Depression?

Being clinically depressed is very different from the down type of feeling that all people experience from time to time. Occasional feelings of sadness are a normal part of life, and it is that such feelings are often colloquially referred to as depression. In clinical depression, such feelings are out of proportion to any external causes. There are things in everyone's life that are possible causes of sadness, but people who are not depressed manage to cope with these things without becoming incapacitated.

As one might expect, depression can present itself as feeling sad or having the blues. However, sadness may not always be the dominant feeling of a depressed person. Depression can also be experienced as a numb or empty feeling, or perhaps no awareness of feeling at all.

A depressed person may experience a noticeable loss in their ability to feel pleasure about anything. Depression, as viewed by psychiatrists, is an illness in which a person experiences a marked change in their mood and in the way they view themselves and the world. Depression as a significant depressive disorder ranges from short in duration and mild to long term and very severe, even life threatening.

Depressive disorders come in different forms, just as do other illnesses such as heart disease. The three most prevalent forms are major depression, dysthymia, and bipolar disorder.

Is Depression A Fatal Illness?

Depression must be thought of as a potentially fatal illness. Friends and relatives may be deceived by the casual way that seriously depressed people speak of suicide or self-mutilation. In Fact, these types of comments need to be taken very seriously every time they are heard. They are not casual because to the depressed person, the pain from self-harm seems no worse than the mental pain they are already suffering. Any comment such as, "Everyone would be better off if I were gone," or "I wish I could crawl into a cave and roll a stone over the entry," is a serious warning sign that the depressed person must be taken to a professional who can monitor them. A formulated plan, such as, "I'm going to jump in front of the next car that comes by," means that this is an emergency and immediate professional help is needed, which may require hospitalization.

Depression can shut down the survival instinct or temporarily suppress it. Therefore, depressed suicidal thinking is not the same as the suicidal thinking of other people who have reached a crisis point in their lives. Depressed, suicidal people, give less warning, need less time to plan, and are willing to attempt more painful and immediate means, such as jumping out of a moving car. They may also fight the impulse to commit suicide by compromising by inflicting self-injury (i.e. cutting themselves with razors), in an attempt to distract themselves from severe mental pain. Relatives and friends are likely to be astonished by how quickly such an impulse can appear and be acted upon.

What causes the change in brain chemistry?

A. It can be either a psychological or a physical cause. On the physical side, a hormonal change may provide the initial trigger: some women dip into depression briefly each month during PMS; some find that the hormone balance created by oral contraceptives disposes them to depression; pregnancy, the end of pregnancy, and menopause have also been cited. Men's hormone levels fluctuate as deeply but less obviously.

Certain chronic illnesses have depression as a frequent consequence: some forms of heart disease, for example, as well as Parkinson's. This seems to be the result of a chemical effect rather than a purely psychological one. The chemical changes that characterize depression can also be caused by environmental factors (i.e. death of a loved one, excessive stress, trauma, alcoholism, too little sleep for long periods of time).

Is Depression Contagious?

A. Major depression seems to occur, generation after generation, in some families, but it is NOT contagious. Depression can occur in people with no family history of any form of mental illness. And there probably is no human who is entirely immune to depression if stressed enough.

Types of Depression

What is major depression?

This is a very serious type of depression. Many people with a major depression can not continue to function normally. The treatments for major depression are medication, psychotherapy and, in extreme cases, electroconvulsive therapy (ECT).

Diagnostic criteria:

At least five of the following symptoms have been present during the same two-week period and represent a change from previous functioning; at least one of the symptoms is either:

(1) depressed mood, or
(2) loss of interest or pleasurable activities. (Do not include symptoms that are clearly due to a physical condition, mood-incongruent delusions or hallucinations, incoherence, or marked loosening of associations.)

1. depressed mood most of the day, nearly every day, as indicated either by subjective account or observation by others
2. markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated either by subjective account or observation by others of apathy most of the time)
3. significant weight loss or weight gain when not dieting (e.g. more than 5% of body weight in a month), or decrease or increase in appetite nearly every day
4. insomnia or hypersomnia nearly every day
5. psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down)
6. fatigue or loss of energy nearly every day
7. feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self- reproach or guilt about being sick)
8. diminished ability to think or concentrate, or indecisiveness nearly every day (either by subjective account or as observed by others)
9. recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide

B. (1) It cannot be established that an organic factor initiated and maintained the disturbance (2) The disturbance is not a normal reaction to the death of a loved one
C. At no time during the disturbance have there been delusions or hallucinations for as long as two weeks in the absence of prominent mood symptoms (i.e..- before the mood symptoms developed or after they have remitted).
D. Not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder

Major depression is manifested by a combination of symptoms (see symptom list below) that interfere with the ability to work, sleep, eat; and enjoy once-pleasurable activities. These disabling episodes of depression can occur once, twice, or several times in a lifetime.

What is dysthymia?

This is a mild, chronic depression which lasts for two years or longer. Most people with this disorder continue to function at work or school but often with the feeling that they are "just going through the motions." The person may not realize that they are depressed. Antidepressants or psychotherapy can help.

Diagnostic criteria:

Depressed mood (or can be irritable mood in children and adolescents) for most of the day, more days than not, as indicated either by subjective account or observation by others, for at least two years (one year for children and adolescents)
B. Presence, while depressed, of at least two of the following:

1. poor appetite or overeating
2. insomnia or hypersomnia
3. low energy or fatigue
4. low self-esteem
5. poor concentration or difficult making decisions
6. feelings of hopelessness
C. During a two-year period (one-year for children and adolescents) of the disturbance, never without the symptoms in A for more than two months at a time.
D. No evidence of an unequivocal Major Depressive Episode during the first two years (one year for children and adolescents) of the disturbance.
E. Has never had a Manic Episode or an unequivocal Hypo manic Episode.
F. Not superimposed on a chronic psychotic disorder, such as Schizophrenia or Delusional Disorder.
G. It cannot be established that an organic factor initiated or maintained the disturbance, e.g., prolonged administration of an antihypertensive medication.

Sometimes people with dysthymia also experience major depressive episodes.

 

What Is Bi-Polar Disorder?

Another type of depressive disorder is manic-depressive illness, also called bipolar depression. Not nearly as prevalent as other forms of depressive disorders, manic depressive illness involves cycles of depression and elation or mania. Sometimes the mood switches are dramatic and rapid, but most often they are gradual. When in the depressed cycle, you can have any or all of the symptoms of a depressive disorder. When in the manic cycle, any or all symptoms listed under mania may be experienced. Mania often affects thinking, judgment, and social behavior in ways that cause serious problems and embarrassment. For example, unwise business or financial decisions may be made when in a manic phase.

Is Bipolar Disorder inherited?

There are some people whose brain chemistry is predisposed to depression Others are at much lower risk of depression, even if exposed to the same physical or psychological triggers. The close relatives of people with bipolar disorder are at a higher risk for unipolar depression than the population at large. And there is strong evidence that bipolar disorder has a strong genetic component.

Are Bipolar People More Creative?

There seems to be a link between high creativity and the gene for Bipolar Disorder (manic-depression). Artists and writers often are either bipolar themselves, or have a family member who is. Studies of families in which members of each generation develop bipolar disorder found that those with the illness have a somewhat different genetic make-up than those who do not get ill. However, the reverse is not true: not everybody with the genetic make-up that causes vulnerability to bipolar disorder has the disorder. Apparently additional factors, such as a stressful environment, i.e. an abusive childhood, are involved in its onset.

What are the guidelines for choosing a drug for Bipolar Disorder?

For people with Bipolar Disorder who are depressed there are some major problems. Most importantly, with any antidepressant, there is a possibility that the antidepressant treatment will cause manic episodes. The possibility of an antidepressant causing mania is least when the antidepressant is bupropion (Wellbutrin). The possibility of mania is greatly reduced if depressed, bipolar people are on a mood stabilizer such as lithium (or lithium-type drugs), Tegretol or Depakote when they are started on an antidepressant. Often, symptoms cannot be completely alleviated without adding an anti-psychotic drug such as Zyrpraxa as well. Let your psychiatrist begin with low levels of meds. Suggest that s/he add new drugs one at a time to alleviate guess work when symptoms or relief from symptoms begin.

What is Seasonal Affective Disorder (SAD)?

SAD is a pattern of depressive illness in which symptoms recur every winter. This form of depressive illness often is accompanied by such symptoms as marked decrease in energy, increased need for sleep, and carbohydrate craving. Photo therapy - morning exposure to bright, full spectrum light - can often be dramatically helpful.

What is Post Partum Depression?

Mild moodiness and "blues" are very common after having a baby, but when symptoms are more than mild or last more than a few days, help should be sought. Post part depression can be extremely serious for both mother and baby.

How is bereavement different from depression?

A full depressive syndrome frequently is a normal reaction to the death of a loved one (bereavement), with feelings of depression and such associated symptoms as poor appetite, weight loss, and insomnia. However, morbid preoccupation with worthlessness, prolonged and marked functional impairment, and marked psychomotor retardation are uncommon and suggest that the bereavement is complicated by the development of a Major Depression. The duration of "normal" bereavement varies considerably among different cultural groups.

What is Endogenous Depression?

A depression is said to be endogenous if it occurs without a particular bad event, stressful situation or other definite, outside cause being present in the person's life. Endogenous depression usually responds well to medication. Some authorities do not consider this to be a useful diagnostic category.

What is atypical depression?

Atypical depression is not an official diagnostic category, but it is often discussed informally. A person suffering from atypical depression generally has increased appetite and sleeps more than usual. An atypical depressive may also be able to enjoy pleasurable circumstances despite being unable to seek out such circumstances. This contrasts with the "typical" depressive, who generally has reduced appetite and insomnia, and who is often unable to find pleasure in anything. Despite its name, atypical depression may in fact be more common than the other kind.

Adjustment Disorder with Depressed Mood:

This is the type of depression that results when a person has something bad happen to them that depresses them. For example, loss of one's job can cause this type of depression. It generally fades as time passes and the person gets over what ever it was that happened.

Diagnostic criteria:

A reaction to an identifiable psycho social stressor (or multiple stressors) that occurs within three months of onset of the stressor(s).
B. The maladaptive nature of the reaction is indicated by either of the following:
1. impairment in occupational (including school) functioning or in usual social activities or relationships with others
2. symptoms that are in excess of a normal and expectable reaction to the stressor(s)
C. The disturbance is not merely one instance of a pattern of overreaction to stress or an exacerbation of one of the mental disorders previously described (in the DSM).
D. The maladaptive reaction has persisted for no longer than six months.

Helping a Friend

How can family and friends help the depressed person?

The most important things anyone can do for depressed people is to help them get appropriate diagnosis and treatment. This may involve encouraging a depressed individual to stay with treatment until symptoms begin to abate (several weeks) or to seek different treatment if no improvement occurs. On occasion, it may require making an appointment and accompanying the depressed person to the doctor. It may also mean monitoring whether the depressed person is taking medication.

The second most important thing is to offer emotional support. This involves understanding, patience, affection, and encouragement. Engage the depressed person in conversation and listen carefully. Do not disparage feelings expressed, but point out realities and offer hope. Do not ignore remarks about suicide. Always report them to the doctor. Invite the depressed person for walks, outings, to the movies, and other activities. Be gently insistent if your invitation is refused. Encourage participation in some activities that once gave pleasure, such as hobbies, sports, religious or cultural activities, but do not push the depressed person to undertake too much too soon.

The depressed person needs diversion and company. but too many demands can increase feelings of failure. Do not accuse the depressed person of faking illness or laziness or expect him or her to "snap out of it." Eventually, with treatment, most depressed people do yet better. Keep that in mind, and keep reassuring the depressed person that with time and help, he or she will feel better.

Choosing a Doctor

What should you look for in a doctor? How can you tell if he/she really understands depression?

If you are looking for a psychopharmacologist to prescribe medications to help control your depression there are a number of things to check. If you are in psychotherapy, it is important to ask prospective doctors about their opinions on the psychotherapeutic treatment of depression. Psychopharmacologists who are hostile to psychotherapy are difficult to deal with while you are in therapy.

It is always legitimate to ask any professionals you are thinking about seeing regularly about their understanding of depression, their beliefs about the causes of depression and their philosophy of treatment. You might ask about how often the prospective doctor has worked with people who have had your particular variety of depression. If you have a rapidly cycling Bipolar depression, for example, you should seek a doctor who has much experience dealing with people who have this problem. Prior to the first visit it is important to clarify with the doctor or the secretary the fee of the initial and subsequent visits, the doctor's policy regarding missed and changed appointments, whether the doctor will accept assignment from insurance companies. If you have Medicare or Medicaid it is important to make sure that the doctor sees people with these forms of medical coverage.

Another aspect of the style of doctors is the extent to which they include their patients in the decision-making process. You might ask "How do you go about deciding which treatment is right for me?" See if you are comfortable with the method the doctor describes. Much can also be learned from how doctors respond to questions such as these. There is much difference between a doctor who welcomes such questions and answers them fully and one who is annoyed by them and answers them superficially.

Causes of Depression

What Causes Depression?

The group of symptoms which doctors and therapists use to diagnose depression ("depressive symptoms"), are the result of an alteration in brain chemistry. This alteration is similar to temporary, normal variations in brain chemistry which can be triggered by illness, stress, frustration, or grief, but it differs in that it is self-sustaining and does not resolve itself upon removal of the triggering events (if any trigger can be found at all, which is not always the case.)

Instead, the brain chemistry alteration continues, producing depressive symptoms causing, enormous new stresses on the person: unhappiness, sleep disorders, lack of concentration, difficulty in doing one's job, difficulty caring for one's physical and emotional needs, strain relationships with friends and family. These new stresses may be sufficient to act as triggers for continuing brain chemistry alterations, or they may prevent the brains ability to correct the initial alteration.

Is Chemical Depression For Life?

The depressed person's change in brain chemistry is usually temporary. After 1 to 3 years, brain chemistry may revert to normal without medical treatment. However, it is often serious enough to result in suicidal thoughts or behaviors. A large number of untreated, seriously depressed people will in fact attempt suicide. As many as 17% will eventually succeed.

Can Low self-esteem Cause Depression?

Many, if not most, people with depression can point to some incident or condition which they believe is responsible for their unhappiness. Of course, people with severe depression are prone to virulent and inappropriate guilt and self-hatred. So what they identify as a cause of the depression is not the true cause. Also people are generally more comfortable thinking that their depression has a specific trigger rather than thinking of it as occurring for no specific reason.

Is depression mostly physical or psychological?

This is beside the point. There is only one physical you, and only one psychological you. Depression may be triggered by either physical or psychological events. Most commonly, both are usually involved. It is often difficult to separate the two when one is talking about psychology and neurochemistry. Whatever the basis for it is, depression quickly develops into a set of physical and psychological problems which feed on each other and grow. This is why a combination of physical and psychological intervention has been shown to give the best results for many patients, regardless of any diagnosis.

Why does trauma cause some people to become depressed?

The life events that are most often associated with depression are varied, but the common side-effects of traumatic events are: loss of self-determination, loss of empowerment, loss of self-confidence and loss of interest in pleasurable activities once enjoyed by the person. More profoundly: a loss of self, and a loss of activities that the person identifies him/herself with.

For instance, a man loses the job that had defined him to himself and others; a woman who had spent her whole life preparing for and living the role of wife, supporter, caretaker, is suddenly left alone by divorce or death. In general, any life change, often caused by events beyond one's control, which damages the structure that gave life meaning, is often too traumatic for the person to deal with effectively, and is then prone to depression.

The ability of a person to respond to a traumatic event will depend on many factors, including genetic predisposition, support from friends, physical health, even the weather. It can also depend on internal psychological factors. I.e. when the person's self-esteem is closely tied to the position or state that has been lost.

Symptoms of Depression

How can I know if someone I know is getting depressed?

Once the depressive state has started, both physical and psychological problems will be generated in abundance. Depression that is spiraling downward is a possible way to lose a job or a spouse. Especially when the person is too depressed to work or to communicate? What worse psychological state for coping with a blow to identity can there be than a chemically maintained, profound self-hatred? And what can be worse for self-esteem than watching one's appearance and household disintegrate as they loose the motivation and energy to shower, get dressed, wash dishes or laundry, or choose get out of bed? Health deteriorates as well: some depressed people can't sleep or eat, others sleep constantly. Others eat incessantly, sometimes in order to stay awake, sometimes because it's the only thing that gives a little pleasure or comfort. (Carbohydrates induce production of serotonin, suggesting an element of self-medication)Almost no one has the impulse to exercise or get fresh air and sunshine. Most if not all of these effects form feedback loops, increasing in magnitude and becoming triggers for further depression.

 

Treatment - Therapy

How can a depressed person regain their sense of self?

Therapy can be immensely helpful here. Obviously, not everyone to whom a traumatic event happens becomes depressed. And not every person who becomes depressed has had a catastrophe befall him or her. In fact, if a person suffers a loss and then becomes depressed, it may well be that they weathered the loss in fine style and then succumbed to a much less obvious psychological or biological trigger. Therapy can help them think of the traumatic event, and how they are relating to it, from a productive point of view, rather than to dwell on the negative aspects of it. They can learn skills to empower themselves and strengthen their ego, and their ability to cope.

How can therapy help?

Psychotherapy helps many depressed people to become more self aware and better able to cope with their problems. Often these "problems" have been under the surface for years, festering, creating a foundation for the depression. Help can be sought through individual counseling, group work, or psychoanalysis.

What type of psychotherapy is effective for depression?

A. Two effective methods of psychotherapy for people with depressions are cognitive therapy and interpersonal therapy. Neither psychoanalysis nor insight-oriented therapy has been shown to be effective treatments for people with a depressive disorder. Cognitive (and cognitive-behavioral) therapists can be found in most major cities.

What is Cognitive/Behavioral therapy?

Cognitive therapy points out a persons misconceptions or "cognitive distortions" that affect the way they view themselves. Some common misconceptions are:

All or Nothing Thinking: You look at things in absolute black-and-white terms. ("I don't think cognitive therapy will solve all my problems, so what's the point in even trying." "There's no point in getting started on this, I'm so far behind I'll never catch up.")

Over generalization: View a negative event as a never-ending pattern of defeat. ("I always mess things up". "He's always late.")

Mental Filter: Dwell on negatives and ignore positives. (Example: your boss praises your report but wants a few changes. All you can do is dwell on the criticism.)

Discounting the positives: you insist your positive accomplishments "don't count" or are due to luck.

Jumping to conclusions: a) Mind reading ("My shrink only gave me half of the cognitive distortion list because he hates me."

Magnification or minimization: Blow things out of proportion or shrink their importance inappropriately.

Emotional reasoning: Reason from how you feel: "I feel frightened therefore this must be really dangerous."

"Should statements": criticize yourself or other people based on how you think they "should" act or feel. "I shouldn't have so many cognitive distortions" "I shouldn't be so apprehensive about this". The only "shoulds', "have to" etc. allowed are a) moral shoulds "Thou shalt not kill", b) Legal shoulds "You shouldn't try to smuggle chewing gum into Singapore" or 3) Physical Law shoulds "If I drop this ball it should fall to the ground."

Labeling: Identify yourself or others with their shortcomings: Instead of "I made a mistake" you think "I am an idiot".

Personalization: You blame yourself for something you weren't entirely responsible for or blame others and overlook your own behavior or attitudes.

The first step in cognitive therapy is to learn to recognize cognitive distortions. At first you feel like your whole mind is a hypertext document and every thought you click on reveals some cognitive distortion. To say you "I shouldn't have so many cognitive distortions" or "Now that I've recognized my cognitive distortions I should _easily_ be able to change the way I act or feel " are cognitive distortions. To say "I feel stupid and incompetent when I see that I am always making cognitive distortions, therefore I must be a total idiot" is a whole bunch of cognitive distortions.

Treatment - Medications

There are many types of psychotropic drugs that can alleviate the symptoms of depression. Some work better on certain types of depression than others. These drugs are not habit forming but they need to be monitored regularly by a mental health professional to make sure they are working at the optimum level.

What are the guidelines for choosing a drug?

There are very few kinds of depression for which there are specific antidepressant treatments. At best, choosing the right drug is a game of intelligent guesses. Your psychiatrist is bound to have a favorite drug, which you will be started on at first. If that doesn't bring about the desired results, a new drug will be tried. Because we are all biologically original, it may take a while before the right drug for our depression is found. Be patient, help is out there.

How do you know if a treatment is not working? How do you know when to switch treatments?

Antidepressant treatment (i.e. Prozac, Effexor) is not working when the individual receiving the treatment remains depressed or becomes depressed again. When a recently started antidepressant fails to create improvement, the depressed individual often asks that the medication be stopped, and a new one started. It generally does not make sense to change antidepressants until 8-weeks have elapsed at the maximum tolerated dose. With some tricyclic antidepressants, it is important to check blood levels for the antidepressant before it is stopped. The blood test can tell if the amount in the blood has been adequate. Only after an adequate trial of one antidepressant should another be tried.

How do antidepressants relieve depression?

There are several classes of antidepressants, all of which seem to work by increasing levels of certain neurotransmitters (most commonly serotonin, norepinephrine, and dopamine) in the brain. It is not entirely clear why increasing neurotransmitter levels should reduce the severity of a depression. One theory holds that the increased concentration of neurotransmitters causes changes in the brain's concentration of molecules, to which these transmitters bind. In some way it is the changes in the receptors that are thought responsible for improvement.

Are Antidepressants just happy pills?

No matter what their exact mode of action may be, it is clear that antidepressants are not "happy pills." There is no street-market in antidepressants, for unlike "speed" which will improve the mood of almost everybody, antidepressants only improve the mood of depressed people. Also unlike the almost instant effects of speed, the mood-improving effects of antidepressants develop slowly over a number of weeks. "Speed" induces a highly artificial state, antidepressants cause the brain to slowly increase its production of naturally occurring neurotransmitters.

What percentage of depressed people will respond to antidepressants?

Generally, about 2/3 of depressed people will respond to any given antidepressant. People who do not respond to the first antidepressant they have taken, have an excellent chance of responding to another.

Will I feel euphoric if my depression responds to an antidepressant?

The most common description of the effects of antidepressants is that of feeling the depression gradually lift, and for the person to feel normal again. People who have responded to antidepressants are not euphoric. They are not unfeeling automatons. The are still able to feel sad when bad things happen, and they are able to feel very happy in response to happy events. The sadness they feel with disappointments is not depression, but is the sadness anyone feels when disappointed or when having experienced a loss. Antidepressants do not bring about happiness, they just relieve depression. Happiness is not something that can be had from a pill.

What are the major categories of antidepressants?

There are many classes of antidepressants. Two kinds of antidepressants have been around for over 30 years. These are the tricyclic antidepressants and the monoamine oxidase inhibitors. While there are newer antidepressants, many with fewer side effects, none of the newer antidepressants has been shown to be more effective than these two classes of drugs. In fact, many people who have not responded to newer antidepressants have been successfully treated with one of these classes of drugs.

The tricyclic antidepressants (TCAs) include such drugs as Imipramine (Tofranil, amitriptyline (Elavil), desipramine (Norpramin), nortriptyline (Aventyl and Pamelor).

The monoamine oxidase inhibitors (MAOIs) include tranylcypromine (Parnate), phenelzine (Nardil), and isocarboxazid (Marplan) which has recently been taken off the market in the U.S.A. for marketing rather than safety or efficacy reasons.

One class of antidepressants are the selective serotonin reuptake inhibitors (SSRIs). The first of these drugs to be marketed in the USA was fluoxetine (Prozac). Sertraline (Zoloft), and paroxetine (Paxil) soon followed, and fluvoxamine (Luvox) is scheduled to be marketed in late 1994, or early 1995.

Bupropion (Wellbutrin) is the only drug in its class, as is Trazodone (Desyrel). The most recently marketed antidepressant (4/94) is venlafaxine (Effexor), the first drug in yet another class of drugs.

How can I measure the effects my treatment is having on my depression?