Mood

Depression - A Closer Look

Depression is a total assault on the body as well as the brain.

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 more art than 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.

Updated May 12, 2007, reviewed Feb 10, 2008

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