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When used as a descriptive word “depression” can mean low mood, dejection, boredom, disappointment etc. These feeling states are not an illness of depression, or a clinical depression in a medical sense as described below, and are normal feelings or reactions for everyone.

Dejection or low mood may be triggered by situations that stimulate minor defects in one’s self esteem that everyone has and that are not usually in conscious awareness. These might be when ignored by peers, passed up at work for a good job, rejection in romance, etc. These problems are usually mild and self-limiting and not in need of any intervention such as counseling unless the stress or sensitivity is really great.

Personality Disorder & Depression

Persons with deeper or a greater number of deficits in their self identity (i.e., having core issues or mental schemas of feeling unloved, unwanted, belittled, unvalidated, incompetent, etc.), may have a more pervasive nature of low mood related to these core issues or deficits in the “Self” or personality. This low mood may be worsened by situations that stimulate these deficits (like being ignored, rejected, etc.).

The dejection and low mood these persons feel is related to faults in their identity or personality structure, like a software problem, but they are not illnesses of the brain per se, like a hardware problem. Persons whose personality is affected to a significant degree may fit the criteria for a personality disorder. Intensive psychotherapy aimed at personality reorganization is the preferred treatment for these problems. Usually a mixture of various approaches including Psychodynamic Psychotherapy that uses a Core Issue-Defense paradigm, or that based on Cognitive Therapy will be helpful.

Clinical (Medical or Biologic) Depression

While Clinical Depression (also called major depression) is an illness which has low mood as one of the major symptoms, the word depression can be misleading because the person usually also has many symptoms besides low mood that can be seen in their behavior (slowness, lethargy), cognition (poor concentration, paucity of thought, memory), social relations (avoidance, feeling inferior to others), self esteem (low self-esteem may lead to guilt, hopelessness and suicidal feelings), and physical symptoms (often sleep and appetite disturbance and decreased libido; and sometimes headache, ringing in the ears, dizziness, GI upset, constipation, muscle aches, etc.). One of the main features of depression is a lowering of enjoyment (lowered hedonic ability called "anhedonia"). Another way to look at this is that the threshold for enjoyment is raised which sometimes causes depressed persons to engage in high-stimulation activities (excessive pornography viewing, seeking or engaging in promiscuity, willingness to engage in destructive relationships, risk-taking sports, drug-abuse, etc.) in an attempt just to feel normal.

A partial remission, or an improvement in some but not all symptoms or degree of symptoms is quite common. In addition, the fact that there are so many symptoms besides depressed mood often causes persons who have clinical depression to conclude they don't have an “illness of depression”, and also for partners of persons with depression to have difficulty in accepting the depression if mood has lifted from treatment but some of the other symptoms still remain (“why can’t my spouse clean up the house or get a job” is a common complaint in this situation). Anxiety can also be a significant symptom of clinical depression; please also refer to this page regarding this topic.

The course of depression may be relatively sudden, especially after a stress, however, it is more common to have a prodromal period (a slowly progressive lead-in) over a number of weeks and months. Some persons have clear cycles, and some persons have a chronic waxing and waning course. Persons with cycles often feel that because they come out of their depression they are not really ill, but it is the cycling of depression itself that is the illness. If persons only have cycles of depression they are said to have “unipolar depression”. As an analogy, consider angina, which is chest pain due to lack of blood supply to the heart (usually due to hardening of the coronary arteries). Angina is typically precipitated by exertion, but the person feels fine when they are at rest. It is obvious that these persons are quite ill even at the times they feel fine.

The more a depression is chronic or recurrent, if there is a family history of depression or other mood disorder, and if there was no discrete stressful event leading up to the depression, then the more likely the depression is a naturally occurring internal or "endogenous" illness for that person, and the more likely they will need to take medication over the long-haul (similar to diabetes or thyroid disease). If they were to stop their medications, then they will likely return to their depressed state. It is not because they take medications that they need them, it is that depression is their natural but ill state of being (diabetes is also natural). For example, if you get hit by a car and break your leg, you will need treatment for a broken bone, but once it heals you will not need ongoing bone treatment. If however, you have an inborn disorder of bone metabolism (like hypophosphatasia), then you will have recurrent bone fractures, and need bone treatment for life. The problem is that depression comes on later in life so it is hard to accept that the illness process had been there all the while, even though there were no symptoms. As an analogy, one's arteries may start to become hardened (called atherosclerosis) many years before there are symptoms of hypertension or heart disease, actual symptoms do not appear until the disease process progresses to a critical degree. Many persons that otherwise have a normal upbringing start to feel depressed as a teenager. Of course being a teenager comes with stresses, but most teens do not have depression so that some of these persons may have harbored the gene(s) to become depressed which "turn-on" during puberty, especially if there is a family history of anxiety or depression (it is obvious that genes have an on-off switch because activation of gene expression is what makes the proteins necessary for the physical changes of puberty).

The lifetime risk of depression is 15% for women and 7% for men. The average age of onset is in the mid-late 20’s. There is a 60% risk of relapse if the depression spontaneously improves or if treatment is stopped. Depression is twice as common in first-degree relatives, suggesting some genetic input. Some persons opine that because they have had a difficult or traumatic upbringing that that is the cause of their depression, however, the majority of persons with a traumatic or difficult upbringing do not get depression as an illness.

One of the biggest issues in persons with depression is the difficulty often seen in their accepting their illness of depression. One factor is the chronicity of depression. Depression is often mild to moderate and chronic. A chronic mild depression is called dysthymia. These persons tend to recalibrate themselves to conclude that a mild amount of low mood, low energy etc. is normal, and they only come in for help if they really go much lower below the line which is called a “double depression” (also described in the dysthymia link). Many persons are stoic and persevere through many years of low mood until they fall farther down. Then they may come for help, but they still may not easily accept their illness. This is also related to not wanting to accept any personal weakness, not an easy task when one is already depressed. Rationalization and denial are common psychological defenses used in the service of avoiding the acceptance of having depression.

Often persons are seen who have lots of talent, and because of this high capacity they can still function well (though far below their level)-sometimes deceiving themselves or even their therapist that they do not have depression. This might be a physicist who lost their ability to conduct their own research and now proofreads other physicists' research papers; or a successful M.B.A. who could not concentrate or handle the stress at a company who now teaches English conversation, etc. Depressed persons who also have episodes of mania (see below) will often aggressively blame others for all their faults (a type of projection).

We will now look at the causes of depression, describe some other types of depressive and mood (also called “affective”) disorders, and then finally the treatments for depression will be discussed.

Go to depression page two.

Summary of Depression Links

DepressionPersonality DisorderPsychodynamic PsychotherapyCore Issue-DefenseCognitive TherapyAnxietyUnipolar DepressionDysthymiaRationalizationDenialManiaPub MedHypothalamic-Pituitary-Adrenal AxisCytokinesNeurotrophic FactorsSerotonin Transporter AlleleMolecular Biology StudiesRecurrent Brief DepressionCircadian RhythmsProjectionAtypical Depressionbipolar disorder (Manic Depression)Mixed StateDiagnostic and Statistical Manual of Mental Disorders-IVBipolar IICyclothymiaHypomaniaMedication-Induced ManiaPost-Partum DepressionSeasonal DepressionPremenstrual Dysphoric DisorderAntidepressantsDepression Treatment

Counseling Tokyo provides counseling, support, and advice, for both the international community in English, as well as the local Japanese community in Japanese.