Depression

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 person’s 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. Person’s 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 prostitution, 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 with who have clinical depression and 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.

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 physicist’s 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.

Causes of Clinical Depression

Depression may be partly associated with personality disorder and psychological sensitivity as noted above, or it may be mostly biological as will be discussed in this section. Biological depression may make one’s personality seem more disordered and vice-versa. Many persons with depression often conclude there was a problem in their upbringing, and maybe there was, but often they confuse meaning and cause. Any significant life event of course has meaning for the person, but it may not be the cause of the problem. Most persons with tough childhoods don’t get depression; but if you have both it is easy to make cause and effect conclusions.

While the details are beyond the scope of this web site, there are also an enormous number of studies and findings on the biologic nature of depression. For example, if you put the search terms, "genetics of depression", or "serotonin transporter in depression", or "brain scans in depression", or "neurobiology in depression", etc. into the Pub Med web site of the U.S. National Library of Medicine or other search engine, you will find an extensive literature related to biologic findings in depression.

A consistent finding is that of overactivity in the hypothalamic-pituitary-adrenal (HPA) axis (possibly from stress) leading to increased tone of the sympathetic nervous system that then causes the release of cytokines (substances usually released when there is some inflammation) that promote the development of depression. Another is that a deficiency of neurotrophic factors that help the growth and survival of nerves in an area of the brain called the hippocampus can lead to depression. Antidepressants are known to normalize the HPA axis, and also to increase the production of neurotrophic factors. An interesting finding is that persons with one type of genetics (the short form of the serotonin transporter allele) are more sensitive to developing depression secondary to outside stress compared to those without these genetics. This shows the interaction between environment and heredity, but again, as most persons would not get depressed with this kind of stress, it is not unreasonable to see the major cause as biologic in nature. Otherwise, it would be like saying that eating chocolate cake interacts with genes in those susceptible to diabetes so that diabetes is not due to a biologic cause.

Types of Clinical Depression

This discussion assumes there is no substance use involved. Persons who use cocaine, ecstasy, LSD, and other substances may induce a mood disorder in themselves, the characteristics of which may differ from the discussion below and are beyond the scope of this web site.

Dysthymia

Dysthymia is a chronic mild depression. It has a lifetime Risk of 6%. These persons often come for treatment when their depression gets worse, and sometimes when something happens that forces them to see that their moods and energy levels are seriously impairing their ability for success. Most of the ideas noted in the clinical depression section above also pertain to dysthymia.

Recurrent Brief Depression

Recurrent Brief Depression (RBD) is defined as short-duration (less then 14 days, usually 2-3 days) of depressive episodes occurring at least once a month over at least one year, not related to menses in women. These episodes may be severe, have associated anxiety, irritability and over-sleeping. The lifetime prevalence of RBD has not been clearly established because studies did not clarify RBD with and without a history of other mood disorders, however, the DSM-IV field trial estimated the life-time of RBD only to be about 2%.

Many persons seen in the Counseling Tokyo offices have on and off short periods of depression, often concluding that they are part of their personality or circumstances, not seeking help until they have a more severe episode. The frequent nature of RBD occurring in a variety of circumstances indicates that the brain areas disturbed are probably set in a cyclical fashion like many other parts of human neurologic function (e.g., sleep-wake cycles, brain control of hormonal cycles, body temperature cycles, etc., called circadian rhythms).

Atypical Depression

Persons with Atypical Depression usually have overeating instead of a decrease in appetite, oversleeping instead of insomnia, ability to feel some degree of enjoyment in response to positive events, and may show a high sensitivity to being rejected. Actually, a large percent of persons with a diagnosis of depression may exhibit these kinds of symptoms.

The trouble with having this type of depression is that is is often overlooked by both the patient and the therapist as a reaction to stress or a Personality Disorder. Patients with atypical depression may languish in psychotherapy for years with a diagnosis of personality disorder only to find that antidepressant medication finally helps them significantly. Note that both the typical and atypical types of depression may be associated with high levels of irritability instead of depressed mood per se. An astute psychiatrist might diagnose depression in someone who most persons see as only "cranky".

Bipolar Disorder (Manic Depression)

The hallmark of Bipolar Disorder (BPD), also called Manic Depression, is that the patient has manic episodes. They usually also have episodes of depression but not necessarily. Manic episodes are defined as periods of time where the person has an excessive amount of energy which may be described as euphoric, irritable, or both. Commonly the person has racing thoughts, rapid speech, lack of need for much sleep and they still feel well, over indulgence in pleasurable activities that have a high chance for adverse results (i.e., extremes of buying items or investments, using drugs, promiscuity, or even psychotic behavior like directing traffic half naked). The person will usually also eventually have depressive episodes. Some persons even have both manic (rapid speech, racing thoughts, lack of need for sleep, etc) and depressed symptoms (lack of energy, tearfulness, hopelessness, etc.) at the same time (this is called a mixed state).

If the manic symptoms are not severe the person may be said to have hypomania. Persons with hypomania may be very productive, creative and charismatic. The down side is that they may eventually burn-out into exhaustion or full mania, or drop to depression. Others may not be able to keep up with their energy level, they may have a level of irritability and aggression, and they may go to excess in pleasurable activities (i.e., dangerous sports, substance abuse, promiscuity, etc.)

BPD affects 1% of the population, with an equal ration of men and women. The average age of onset is around 20 years-old. Depression, hypomania, and Bipolar Disorder are much more common in first-degree relatives of persons with BPD suggesting a genetic component. The concordance rate for monozygotic twins with bipolar disorder is about 70%. If you put “genetics and bipolar disorder”, or “biology and bipolar disorder”, or “brain scans and bipolar disorder in the Pub Med web site of the U.S. National Library of Medicine, you can get a feel of the biologic findings and nature of BPD.

Many persons with bipolar disorder are talented and creative. Some have made volumes of great artistic or scientific work in relatively short periods of time. This does not mean it is favorable to have this illness as these persons eventually suffer exhaustion, depression, and alienation of their social circle. In addition, persons with some degree of mania often deny they have any problem, enjoy the energy they have, and do not want to admit any personal weakness. If they have an aggressive mania they will blame others. These factors make it extremely common for persons with bipolar disorder to refuse to accept their illness or treatment.

The Diagnostic and Statistical Manual of Mental Disorders-IV details three major categories of bipolar disorder, bipolar I, bipolar II, and cyclothymia. Bipolar I requires one or more manic or mixed episodes. A depressive episode is not required for the diagnosis of bipolar I disorder but it frequently occurs. Bipolar II, which occurs more frequently, is usually characterized by at least one episode of hypomania and at least one major depression. Cyclothymic disorder requires the presence of numerous hypomanic episodes, mixed with mild depressive episodes that do not meet criteria for major depression. Some psychiatrists will also include medication-induced mania, as well as a family history of mania as subtypes of bipolar disorder.

For completeness we will also note that clinical depression may be seen in the context of post-par tum depression, seasonal depression, or as premenstrual dysphoric disorder.

After reading about all these mood disorders it may become evident that there are a multitude of variations of depression and mania that one can experience. There is evidence that unipolar depression and bipolar depression may be separate disorders, however many patients often fall into a grey area.

Treatment of Depression

Psychotherapy alone may be effective for those with personality disorder based depression and sometimes for mild clinical depression. If the depression is severe, however, treatment with medication is often necessary in addition to psychotherapy or counseling. Many persons are reluctant to take medications because they have not fully accepted the medical nature of their illness, they may be fearful of side-effects, and they may have concern about the stigma attached to taking psychiatric medications. If the depression is really distressing and/or impairing one's ability to function, then one needs to set a priority on getting better in spite of their hesitancies, just as if you have appendicitis you need surgery in spite of the risks.

It is interesting to find many persons who need medication use or have used tobacco, alcohol, speed, marijuana, or other substances proven to be dangerous are reluctant to take antidepressants. It is often useful to counsel persons that if the never try they will never know if a medication can help them (in lieu of the depression ruining their lives), and by definition no one should ever take medication that does not work or that is not easily tolerable to take. Side effects are usually managable if they do occur. If one does take medication, it is also important to take enough. While too little will not work well, many persons only want to accept they are “mildly ill” so that only “mild doses” are needed.

Even when a person takes a medication, they often want to stop when they are better. This is a complex situation that needs careful discussion. Often persons are better because they are on the medication; not that they are better so they can stop the medication. Also, effects of medications on one’s nervous system may last many weeks or months so that concluding one does not need medication because they are still well 2 months after stopping may not be a valid conclusion. Sometimes persons fear that they will become dependent on the medication. In this case it is sometimes helpful to explain to them that if they stop the medication they will go back to their natural self that is depressed, and that in this case “natural” may not necessarily mean “healthy”. Just as if someone with diabetes stops their insulin, or someone with hypertension stops their antihypertensive meds, they will return to their natural and unhealthy state; it is not because they took the medication that they are ill. It is true that if one stops an antidepressant it should be stopped slowly to avoid any recurrence of depression and/or abstinence symptoms of stopping a medication the body has been used to (this is the same for many medications that treat the heart and other medical medicines), but there will be no drug seeking or addiction like a narcotic.

There are also persons who may be able to stop their medication without having a recurrence of depression. The more depression is intrinsic or endogenous (i.e., part of themselves), however, the less likely one can stop without getting the depression back again. Endogenous depression would be suggested by 1. chronic history or multiple recurrences especially when stopping medications in the past, 2. family history (genetic loading), and 3. no serious discrete event to trigger the depression. The fewer of these factors one has the more chance one has to only need one course (at least 6 months) of antidepressant medication.

As a final note, persons with depression have been found to have an increased risk of mortality from certain illnesses. One example is that hardening of the arteries progresses faster in persons with depression which leads to an increased risk for high blood pressure and diseases of the heart, and an increased risk for stroke, etc. This is another reason to take the treatment of depression as a serious matter.

A full and detailed description of all the treatments of depression is beyond the scope of this site. Please refer to this link on depression treatment, as well as other sources.

Summary of the links on this page:

Depression｜ Personality Disorder｜ Psychodynamic Psychotherapy｜ Core Issue-Defense｜ Cognitive Therapy ｜ Anxiety｜ Unipolar Depression｜ Dysthymia｜ Rationalization｜ Denial｜ Mania ｜ Pub Med｜ Hypothalamic-Pituitary-Adrenal Axis｜ Cytokines｜ Neurotrophic Factors｜ Serotonin Transporter Allele｜ Recurrent Brief Depression｜ Circadian Rhythms｜ Projection｜ Atypical Depression｜ bipolar disorder (Manic Depression)｜ Mixed State｜ Diagnostic and Statistical Manual of Mental Disorders-IV｜ Bipolar II｜ Cyclothymia｜ Hypomania｜ Medication-Induced Mania｜ Post-Partum Depression ｜ Seasonal Depression｜ Premenstrual Dysphoric Disorder｜ Antidepressants ｜ Depression Treatment