You know you're depressed. Your brain has just crashed. Perhaps it was a two-lobe pile-up that left you in a state of shell-shock, barely able to respond to your surroundings. Perhaps it simply refused to start, like a car with a dead battery, so you gave up on the day, hoping you would be able to turn the engine over sometime in the future, whenever you were able to get yourself out of bed, assuming you could see that far ahead.

Depression Symptoms

Strangely enough, you don’t have to feel depressed to have clinical depression. The Diagnostic and Statistical Manual for Psychiatric Disorders, Fourth Edition, Text Revision (DSM-IV-TR), the diagnostic Bible put out by the American Psychiatric Association, in its criteria for major depression lists EITHER feeling depressed most of the time for two weeks OR abnormal loss of interest or pleasure most of the time for two weeks. This dichotomy effectively divides depression into an either-or choice of exaggerated sadness on one hand or lack of emotion on the other.

Feeling BOTH depressed AND having no pleasure? Don't worry. The DSM-IV has thoughtfully provided a nine-item menu choice that gives you a second crack at the first two, namely (in slightly edited form):

• Abnormal depressed mood (or irritable mood if a child or adolescent).

• Abnormal loss of all interest and pleasure.

• Appetite or weight disturbance, either weight loss or weight gain.

• Sleep disturbance, either abnormal insomnia or abnormal hypersomnia.

• Activity disturbance, either abnormal agitation or abnormal slowing (observable by others).

• Abnormal fatigue or loss of energy.

• Abnormal self-reproach or inappropriate guilt.

• Abnormal poor concentration or indecisiveness.

• Abnormal morbid thoughts of death (not just fear of dying) or suicide.

The DSM-IV mandates having at least five symptoms, though in actual clinical practice having only three or four is hardly going to rule out treatment. What is striking about the list of symptoms is that four of them can be considered physical in nature.

The DSM goes on to note that these symptoms should not be attributable to other mental causes, substance use, a general medical condition, or bereavement, but this is not the same as saying a depression materializes from nowhere.

Not too long ago, psychiatrists distinguished between endogenous and exogenous depression, the former thought to have been caused by a patient's biological processes and the latter by outside circumstances such as bereavement. These days, depression is regarded as the result of interaction between genes, environment, past experiences, and biology. Stressful events can trigger a depression and bad lifestyle choices or circumstances or past trauma can make one a sitting duck (see articles in the Lifestyle and Science sections).

Your doctor may give you a "depression test." The most common is the Hamilton Depression Rating Scale (HAM-D), used by clinicians and researchers to assess the severity of one’s depression and to measure one’s improvement (if any) over the course of treatment or a clinical trial. The HAM-D includes the DSM-IV symptoms (some listed more than once), plus anxiety (including physical anxiety symptoms such as heart palpitations or sweating), sexual dysfunction, and general aches and pains such as backache. These symptoms should arguably be included in the DSM, and perhaps in the next edition one or more of them will.

Functional Impairment

Please note that the DSM-IV is as much a product of art as it is science. There are no clear-cut biological markers for depression, with no lab tests or blood screenings to determine that you have the illness. Thus, the DSM-IV should not be regarded as something written in stone. Technically, five or more symptoms are regarded as the threshold, but a person suffering intensely from just three or four may be a lot more depressed than one who experiences a little of each.

At an Ask the Doctor session at the 2004 Depression and Support Alliance (DBSA) annual conference, David Kupfer MD, chair of the department of psychiatry at the University of Pittsburgh, said he "doesn’t like the Chinese menu approach" of the DSM-IV. The number of symptoms, he said, is not as important as impairment in functioning, even if that involves relatively few symptoms.

Indeed, functional impairment can be a more important indicator of depression than quibbling about symptoms. According to the World Health Organization, major depressive disorder is the leading cause of disability in the US and established market economies worldwide. A 2001 DBSA survey reported that prior to being treated, 76 percent said that depression limited them in sleeping, 70 percent in social activities, and 69 percent in lifestyle. Sixty-two and 58 percent, respectively, reported that physical activities and work motivation were affected, and 52 percent said that depression had a negative effect on their loving relationship.

Depression isn’t the word for it. Brain crash is more like it. It is a total assault of the body as well as the brain, every bit as much a physical illness as mental. Our ancestors had every right to confuse mental illness with demonic possession. This is an illness that lays waste to the body as well as the mind. You can't think, you can't move, you can't function.

Small wonder people can’t take it. "Well, my own work," Vincent Van Gogh wrote in his last letter to his brother Theo, "I am risking my life for it, and my reason has half foundered." Six days later, he would be dead, a bullet to his chest, an act of suicide.

Different Types of Depression

The DSM-IV gamely attempts to break down different types of depression according to symptoms or circumstances, but until we can do it according to biology and genes even the experts are flying in the dark. Even in the same individual, no two depressions are alike. A 2003 Columbia University study examined 78 inpatients with major depression during two separate episodes, and found there was little association between the symptoms across episodes. The authors of the study used the word “pleomorphic” to describe the illness’ uncanny ability to assume different forms in the same person.

In this section, you will find articles on different types of depression, including dysthymia (mild to moderate depression, under the article title, "Mental Water Torture"), seasonal affective sisorder (winter depression), atypical depression (as opposed to melancholic depression), and agitated depression (under the title, "Multipolar Depression).

In the Behavior section, it is worth checking out two very important features of depression, namely apathy and loss of pleasure.

In the Special Populations section, you can read about post-partum depression.

Also, keep in mind that there are very important spectrum considerations, involving depression overlapping into symptoms of bipolar disorder. You may not have bipolar, but your depression may behave like bipolar. Accordingly, as well as Multipolar Depression, also check out: The Mood Spectrum, Hard Depression, Soft Bipolar, and The True Meaning of Manic-Depression

The DSM mentions "psychotic depression.." Since this is not included as a separate article on this Website, a brief mention is warranted here:

With psychotic major depression, one’s thoughts of guilt and worthlessness and hopelessness cross the line into the realm of delusion. The DSM cites examples of “mood congruent” features, including holding oneself responsible for the death of a loved one or deserving to be punished for some moral transgression or personal inadequacy. One can also experience delusions of illness or poverty.

Less common are “incongruent” features that include delusions of persecution and the belief that one’s thoughts aren’t one’s own. Those in a state of psychotic depression can also experience hallucinations such as hearing voices.

Not surprisingly, individuals with psychotic depression are more likely to wind up in the hospital than their nonpsychotic counterparts, accounting for 25 percent of hospitalized depressed patients. Recurrences are common, and treatment is problematic, though we are learning more, especially since the advent of a new generation of antidepressants and antipsychotics, which can be effective when taken as a combination.

Situational vs Clinical Depression

The best way to explain depression to a friend is to ask that person to recall what it was like when a loved one died. But grief is a normal response to the death of someone close to you, and is not regarded as pathological. Only when bereavement lasts for two months of more, says the DSM, should we reconsider the diagnosis.

The same thinking goes into the DSM's requirement that a depressive episode go on for two weeks or more. As an example, psychiatrists noticed a lot of their patients reporting depression soon following the 2004 election (it is fair to say they would have received similar reports from a different set of patients had the results gone the other way).

Perhaps, if you were on the losing side, you handled your disappointment well. But there were some, no doubt, who began to think like classic depression cases, despairing, with dark thoughts, and perhaps with no will to go on. But it's difficult to imagine this going on for two weeks. Pretend one of these individuals has his daughter's wedding is coming up. In a few days, his situational depression is likely to abate, and once again he will be looking forward to walking the apple of his eye down the aisle.

Contrast this with Hall-of-Famer quarterback, Terry Bradshaw, who has publicly acknowledged a life-time history of depression. Not even his four moments of triumph could snap him out of it. As Bradshaw told the news media: "I didn't understand that after every Super Bowl victory, I could never find pleasure in what I'd done.”

If you think of Terry's brain as a computer, his software was basically filtering out all that should have brought him any sense of accomplishment and joy.

But there is another kink to this. Let's go back the case of the father of the bride. Call him Ishmael. Let's suppose that Ishmael's brain has been biologically predisposed to depression since birth, and that the condition had remained dormant all his life, waiting for the right trigger to set it off. This time, instead of recovering in a few days, Ishmael continues to feel like a dead man walking. He manages to drag himself to work, but he's just going through the motions. Several months pass. He walks his daughter down the aisle, but he is as indifferent as Terry Bradshaw after winning a Super Bowl.

Personal Note

From my book, Living Well with Depression and Bipolar Disorder (HarperCollins (2006):

"It was only a question of working up the courage. But the way things were going, courage would no longer enter into it. Just a little deeper into the Mount Everest Death Zone, I knew, and it wouldn't be a matter of me committing the act. The act, instead, would commit me. The rope would tie its own noose, the pond's frigid waters would warmly embrace me, the bridge would obligingly throw me off ...

"But at the last minute I chickened out. I chickened out. That's how I felt at the time. I stood in my mother's kitchen, back to her, hands clutching the sink, and called out for help. The total illogic of the decision stunned me. It made no sense to a person in my condition. I had chosen life over death.

"I don't kid myself. I will always be an emergency room case waiting to happen. Once you have emerged from the Death Zone and lived to tell the tale you are never the same. On one hand I am amazed at my strength in surviving the ordeal, on the other I am humbled by the fact that I am no more than a leaf in a tornado to my condition."

Making the Depression Diagnosis

Now for the standard warning label: YOU may know that you are depressed. But the final diagnosis is not for you to make. The true culprit could be physical (such as the thyroid or a hormonal imbalance or a side effect to an illness or its treatment, or a reaction something you are eating).

Accordingly, a thorough physical checkup is highly recommended. Likewise, your depression may stem from related mental illnesses, such as bipolar, or from hybrid illness syndromes such as fibromyalgia. Your depression might also be tied in to alcohol and substance use, which would necessitate a more considered treatment strategy. A competent doctor or psychiatrist will make the final determination. YOUR job is to make sure you place yourself in reliable hands.

Be sure to tell your doctor, therapist, or psychiatrist everything. Depression can be hard to spot, particularly if you are young or old. All a diagnostician has to go on is what you tell him or her. Your sense of shame may be your own worst enemy here. This is especially ironic when you consider that in getting a physical check-up, you are probably most willing to sit half-naked in a sterile exam room for a half-hour to show a relative stranger parts of your anatomy your own spouse has never had a good look at.

You have nothing to hide. You have found the courage to go for help. Now the healing can begin.

Browse depression books here.

For free online issues of McMan's Depression and Bipolar Weekly, email me and put "Sample" in the heading and your email address in the body.

Updated May 12, 2007

Diagnosis articles All Articles

Click image for next article in guided tour.

Discussions

Mary (April 29, 2003): I am 49, female. I have suffered from severe from 22 until about 39, contributing to society and rejoicing in personal academic and workplace achievements. A tricyclic drug, desipramine was the only drug that worked ( and just about ever every new drug on the market worked, at my suffering through the trials ) However, I did have "breakthroughs".
Depression is the deepest, darkest, loneliness place a person can be. Regardless of who is around you--husband, children, family. You want to die so that they won't be burdened with your ongoing illness any longer. Neighbors whisper about you. You can't hide it. You need immediate help and doctors fail to tell you that it takes about 4 to 6 weeks to feel the positive of a particular drug-if there are positive effects.

Try to rejoice in your family and friends. If you were to die at your own hand, you would leave a horrible legacy with your children and loved ones for generations to come. Accept what you have. Clinical depression has not been fully characterized in this article. I urge you to read other articles on the web sight.

By the way, I have a horrible case of bipolar disorder. After 8 years, with Dr. Ketter's help, I am now on a regimen that makes me feel human again. Energy, good feelings, bad feelings, being tired and lazy, sleeping 6 hours, sleeping 10 hours--all in an appropriate manner (I suffer from severe mania too). Be your best advocate. Study the internet for the latest treatments available, their pros and cons. Discuss with your doctor. If he or she takes offense, get a new doctor FAST. Interview your doctors. Your life is in their hands. Ask them how they stay current is their field and when they introduce new drugs into their practice.

Good luck and God bless you.

Anonymous (June 7, 2003): I am 58 years old and i can remember as a teenager i was always depressed. my friends remind me of my mood swings and crying spells. I have been treated for over 40 years for depression and just now realizing that I think I have manic depression and I always have a very very low (crying spells and down, moody) and then I'm as friendly and high as i can be. I don't want to be this way. no psychiatrist has ever mentioned this to me as I was always so sensitive and always going through some sort of a crisis, either death, divorce, separation,, etc. so they said I was depressed. I am now on 100 mg of Zoloft and still feel very high and very low. I am unable to find a doctor who will recognize this and treat me according, as I am very sensitive to medication. any recommendations.

Tigerduck (June 24): I'm unspeakably grateful for the articles on this site, but as I read, I get very frustrated as I try to make sense of the official lists of symptoms that should presumably help a person to determine which condition he/she is suffering from. It's not the fault of the website, of course--just a reflection of the fact that, even today, when the future looks brighter than ever for sufferers of mood disorders, the psychiatric community STILL can't say with any certainty what the fundamental, neurological difference is between one condition and another (between bipolar and unipolar depression, between bipolar II and atypical depression, between bipolar and ADD (which I realize falls outside the domain of this site)), and certainly can't hope to present a dependable, watertight group of symptoms to guide people to a sure diagnosis.

For example, a study cited in the "Multipolar Depression" article here concluded that bipolar IIs experience more hypersomnia, while unipolar depressives feel that they have no energy. I personally experience both--the hypersomnia during the 12 hours a day when I'm asleep, and the "having no energy" during the 8 hours I'm awake. At any rate, it hardly seems like a useful distinction. In this same study feelings of guilt were associated with bipolar II--but feelings of guilt are also listed by the DSM as symptomatic of depression.

There also seem to be many similarities between bipolar disorder and ADD--the inconsistencies in perception of time, the unpredictability and great range in a person's ability to perform well at a task, and the trouble refocusing attention that are described so eloquently in the "Bipolar or Bichronic" article are also mentioned in literature on ADD.

Along similar lines, I am annoyed by the primness with which the DSM states, for example, that "abnormal agitation or abnormal slowing" are symptomatic of depression, but only if they are "observable by others." In my opinion, as a depressed person who has pulled off a successful imitation of a non-depressed person off and on for years, I think the depressed person her/himself is in a much better position to make this judgment.

And, according to the DSM, "excessive or inappropriate guilt" is a depressive symptom, BUT merely feeling guilty about your illness doesn't count. This strikes me as a ridiculous distinction.

And there's the DSM's statement that "abnormal morbid thoughts of death or suicide" are a symptom of depression, but that mere fear of dying doesn't cut it. Huh??! Why not? What if I were to suffer through an entire summer when all I could think about (with great fear) was my own eventual death, when for horrifying moments I had the sensation that my lifetime was a tiny speck in eternity and was as good as snuffed out already, and finally one night actually got out of bed and fainted from terror? (this did happen to me.) If THAT's not depressed, what is?

At any rate, I suspect that the boundaries that are currently drawn between these various disorders will be shifted around and redrawn a time or two before we get to the real truth of things.

McMan (June 24): Hi, Tigerduck. One day we're going to look back at this as the dark ages. I'm guessing that 10 years from now, genetics, neuroscience, and brain imaging will combine to give us a far more precise diagnosis, and that what turns up on our gene scan, brain scan, and lab tests will help determine the type of treatments we get.

Mizunderstood Diztopian Angel (Aug 5, 2003): They will never truly know. Never. No one down here is God.

TrueBlue (Oct 8, 2003): Tigerduck you are spot on. My impression is the various "diagnoses" are broadbrush placeholders that sometimes confuse the doctors as much as they do patients. Seems more useful (and I've seen it advocated) to just focus on the collection of symptoms, and regard any specific diagnosis with a grain of salt. Line up the symptom lists for bipolar II, cyclothymia, atypical depression, borderline personality disorder, ADD...the distinctions are so minor that a specific diagnosis seems not terribly informative. This is borne out in practice: treatment is informed trial-and-error, with medications approved for one diagnosis frequently prescribed for others (e.g. anti-psychotics for depression, anti-seizure drugs for bipolar, depression medications for OCD). As a fellow with treatment-resistant "whatever" (depression, ADD, bipolar II or cyclothymia...pick or combine any of the above) I've come to appreciate most a doctor who readily admits the above, and then patiently goes about trial and observation and tweaking and combining to find things that help...and I have been helped at times. Good luck to one and all.

Susan (Nov 13, 2003): Thank you, Tigerduck. Very well put! I am grateful for this website, McMan has done us a service by not being pedantic and allowing for the fact that we have a long way to go in diagnosis and treatment. There are many, many shades of gray for all the medical psychological disorders we face and that makes it all the more complicated. I am a pitbull about getting medical help for my disorder, sometimes I feel I am the one who is doing all the work. No one should have to beg to get medication or be taken seriously in a ludicrous allotment of fifteen minutes per session for something extremely medically serious. It is a disgrace. Thank you McMan for helping many of us feel you are at least on our side.

Post your opinion here.

Click image for next article in guided tour.

John McManamy

Order my book on Amazon

Order now

Newsletter

Your online source for issues that matter to you.

For free samples, email me and put "Sample" in the heading and your email address in the body.

Find out more.

Bookstore

Shop for depression and bipolar books online here.

The next time someone says depression is all in your head, show them this PET scan of the brain of someone with depression. Scans of healthy subjects show far fewer cases of "the blues."