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
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
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
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
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.
Some researchers have found 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 suggests (but not proven yet) that there may be 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. Finally, molecular biology studies are beginning to show that specific "molecular signatures" may be found in persons with depression.
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 (Persistent Depressive Disorder)
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).
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
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,
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
The Diagnostic and Statistical Manual of Mental
Disorders-IV details three major categories of 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.
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
mania, as well as a family history of mania as subtypes of
For completeness we will also note that clinical depression
may be seen in the context of post-par
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
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
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:
Cognitive Therapy ｜
Serotonin Transporter Allele｜
Molecular Biology Studies｜
Recurrent Brief Depression｜
bipolar disorder (Manic Depression)｜
Diagnostic and Statistical Manual of Mental Disorders-IV｜
Post-Partum Depression ｜
Premenstrual Dysphoric Disorder｜