ADVANCE PRAISE FOR DEPRESSION: WHAT EVERYONE NEEDS TO KNOW®
“For anyone seeking information about the nature of depression, why it happens, and how it can be assessed and treated, this is your book. Even for those who already know a lot about depression, the comprehensive up-to-date information and the beautiful writing style will make this a bookshelf favorite.”
Sheri
L. Johnson, PhD, Professor of Psychology, Director, CALM Program, University of California Berkeley
“This book is a must-read for anyone interested in and/or affected by depression. Written by a foremost expert on depression theories and treatment, it combines the presentation of cutting-edge knowledge with thoughtful and empathic descriptions of the main symptoms and treatment approaches. The book not only provides important information, it also offers hope and practical advice to people confronted with the disorder. It should be of great interest to anyone interested in understanding and treating mental disorders.”
—Jutta Joormann, PhD, Professor of Psychology, Department of Psychology, Yale University
DEPRESSION
WHAT EVERYONE NEEDS TO KNOW
®
JONATHAN ROTTENBERG
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Names: Rottenberg, Jonathan, author.
Title: Depression : what everyone needs to know / Jonathan Rottenberg.
Description: New York : Oxford University Press, 2022 |
Series: What everyone needs to know | Includes bibliographical references and index
Identifiers: LCCN 2020058294 (print) | LCCN 2020058295 (ebook) | ISBN 9780190083144 (paperback) | ISBN 9780190083151 (hardback) | ISBN 9780190083175 (epub) | ISBN 9780197586808
LC record available at https://lccn.loc.gov/2020058294
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For Ollie and Cy
CONTENTS
ACKNOWLEDGMENTS
PART I: DEFINITIONS OF DEPRESSION
1. The Challenge of Defining Depression
What is depression?
How has depression been defined throughout history?
2. The Syndrome of Clinical Depression
What are the symptoms of depression?
How is clinical depression different from a sad mood?
How does clinical depression range in its severity?
What is the difference between unipolar depression and bipolar disorder?
3. When Should I Worry That I Might Be Depressed?
Case Study: Jose
Can I self-diagnose?
What are better ways to diagnose depression?
4. The Prevalence of Depression
How common is depression?
Is the prevalence of depression increasing?
A depression epidemic? Sorting out the evidence
5. The Consequences of Depression
How does depression impact mental and physical health, relationships, and careers?
Which mental health problems usually co-occur with depression?
Why does depression so often co-occur with other mental health problems?
Does depression ever have any positive consequences?
PART II: ORIGINS OF DEPRESSION AND THE DEPRESSION EPIDEMIC
6. Biological Contributions to Depression
Is depression a “chemical imbalance”?
Is depression due to bad genes?
What has research on the brain taught us about depression?
7. Environmental and Psychological Contributions to Depression
Is depression the result of stress?
Does depression stem from negative thoughts?
Does depression stem from relationship problems?
Can depression result from childhood events?
8. Depression Throughout the Life Course
Can children have depression?
Why does depression spike during adolescence?
Why are women more likely than men to have depression?
What is depression like in older people?
9. Depression Over Time
If I have depression, will it come back?
What is chronic depression?
Is there such a thing as a depressive personality?
10. Why Is There an Epidemic of Depression?
A mood science approach to the depression epidemic
How modern routines disturb mood
Does social media play a role?
The perils of a happiness-obsessed culture
Young persons: The future of the depression epidemic?
PART III: REMEDIES FOR DEPRESSION
11. What Are My Treatment Options?
What are the best treatments for depression?
Cognitive–behavioral therapy
Interpersonal psychotherapy
Medication treatments for depression
Other important treatment options
How effective are different depression treatments?
How should I decide which treatment to try?
How can I find a competent treating professional?
Final quick pep talk: Top five reasons to consider treatment
12. What Can the Depressed Person Do for Themself?
Start from where you are
Do self-help books help depression?
What about the role of exercise, sleep, or pets?
How can I discover my secret weapon against depression?
13. How to Talk About Depression and Help a Depressed Person
Why is depression so difficult to talk about?
Breaking down conversation barriers
What else can you do to help a friend or family member who is depressed?
When depression becomes a crisis
PART IV: LIFE AFTER DEPRESSION
14. What Is the Long-Term Prognosis for Depression?
Peering into the future
What is meant by terms such as recovery, response, or remission?
How common is full recovery from depression (and what explains why it happens)?
Can people flourish after depression?
15. Life After Depression
The first day of the rest of your life
Making sense of depression after it passes
What can be learned from depression?
Being prepared for relapse: Recommendations
16. Charting a New Future for Depression
What are the biggest remaining myths about depression?
What can the individual do to improve the conversation about depression?
How can the individual help bring about broader social changes that reduce the toll of depression? Is there really reason for hope?
RESOURCES INDEX
ACKNOWLEDGMENTS
I express my gratitude to Sarah Harrington at Oxford University Press for her care and support with the manuscript. Mary Kleinman helped greatly with research. Members of the Mood and Emotion Laboratory provided early feedback on chapters. Rana Rottenberg provided maternal care and copyediting. Laura Reiley provided nourishment of all kinds.
PART I
DEFINITIONS OF DEPRESSION
THE CHALLENGE OF DEFINING DEPRESSION
What is depression?
A surprisingly difficult question.
Depression has spawned thousands of books. Yet one enduring view is that depression is somehow beyond words (at least when we try to describe the experience). I believe that launching more words (and even another book) about depression is not a futile or vain effort. But let’s grant, the subject is full of paradoxes.
Depression is at once intensely private and the most public of problems. People who go through depression are cut off from others, even as they experience symptoms that are shared by millions.
Clinical depression is at once a pressing crisis the World Health Organization deems it the most burdensome global health problem and a condition met with shrugs. Despite the severity of the problem and the vast number of people affected, depression garners surprisingly little public mobilization. People don’t march against depression or hold golf tournaments or dance marathons to benefit those who suffer.
Another puzzle is that depression exerts the most visible of effects the many calculable losses tallied by epidemiologists and economists be it lost work productivity and income, broken marriages, or even deaths by suicide. And yet, at the same time, depression is also invisible and incalculable. There is no test of blood, urine, or genes for depression. Those affected have no obvious stigmata. There is no single telltale sign of the condition.
Then, there is the great imprecision in how people throw around the term depression. Colloquially, the phrase “I’m so depressed” is said as a response to a multitude of everyday disappointments when rain spoils your picnic, when new couch gets coffee stained, when concert tickets for your favorite band sell out. Such trivial uses of the term depression suggest that depressed people must be whiners and complainers who exaggerate the severity of their problem. Making matters worse, the same term, depression, is also used by clinicians, scientists, and everyday people to mark the most catastrophic of states: when a person is unable to get out of bed, unable to work, unable to self-care, and even consumed by thoughts of suicide. When a single term is used to cover so much territory, widespread confusion about what exactly depression is seems almost inevitable.
So, if we are to cut through the many misunderstandings that surround depression, we need to simplify. Let’s begin with its incontrovertible essence: Depression is a kind of mood. Within us all, we are endowed by evolution with a mood system. This system responds to threats and opportunities in somewhat predictable ways. When we make quick progress toward important life goals, our mood is usually good. When we are blocked in our progress or move away from important life goals, our mood is low. Mood reflects the availability of key resources in the environment, both external (e.g., food, allies, and potential mates) and
internal (e.g., fatigue, hormone levels, and adequacy of hydration), and ensures that any animal does not waste precious time and energy on fruitless or even dangerous efforts, such as doing a mating dance when predators are lurking. Given that resources of every sort be they time, energy, or money are finite, expending resources on unreachable goals can be ruinous.
The mood system is capable of great variety, from energized highs to everyday blahs to the more severe moods we call clinical depression. The mood system has power over our minds and bodies. Depression is the textbook demonstration of this power. Mood colors our thinking: When we are depressed, thoughts turn to loss, failure, or incapacity. Mood biases our actions: When depressed, we may withdraw, cancel plans, or give up entirely. Mood states even influence our physiology. During depression, the body is aroused, locked in a state of dread night after night, sleep will be elusive.
The endowment of a capacity for mood inevitably brings with it the potential for both good moods and bad moods, including the unpleasant mood states we call clinical depression. It is likely that virtually everyone has at least some capacity for depression. However, this does not mean that depression is the same for everyone. On the contrary, depression affects different people in different ways. It has many different faces. For some, depression may come out more as a disturbance in thinking; for others, bodily symptoms and motivational changes might be most prominent; for others still, painful emotions are the focal point. Depression may feel wrong or uncomfortable, but there’s not a right or a wrong way to be depressed. Depression will likely mean different things to the tycoon on his yacht, the homeless woman living under the bridge, the insurance salesman, or the fashion model, with each appreciating their moods through the prism of their own life history and selfunderstanding.
Saying depression is a mood and part of a larger mood system orients us. Being oriented is the first step to helping us think more deeply about what depression is and where it comes from. Much complexity remains. As we will see in the coming pages, many different forces act upon the mood system. These include forces we’re aware of, such as environmental events, the health of our relationships, our diet, sleep habits, physical activity, light exposure, as well as our own thoughts. But the mood system is also acted upon by unseen forces forces of which we are not aware such as the operations of our immune system or stress hormones. Both seen and unseen forces act on the mood system simultaneously. This fact almost guarantees that humans will face a degree of uncertainty about why they are depressed.
This book takes our uncertain posture toward moods as both an assumption and a point of departure for gaining a better understanding of depression. It is natural that the depressed person wonders “Why me?” or “Why now?” and it can be frustrating to individuals or their loved ones when there are no obvious “answers” to these questions. Nevertheless, it is possible to become a more educated consumer of one’s own mood, and this book is intended to provide help toward that end. This education includes how to know the difference between depression and normal mood variation; how to better understand the forces that act on mood; and how to better control those forces, including what individuals can do for themselves and how to access additional help from professionals.
How has depression been defined throughout history?
Depression appears as one of the great perils of our times. We read stories about rising rates of depression and commentary that connects it to contemporary trends such as increased use of social media or the ways a gig economy negatively affects workers. The psychological challenges of living amid the COVID-19 pandemic have also fed perceptions that depression is rising in many countries, perhaps to unprecedented levels. Is depression a modern condition?
A glance at history challenges the idea that depression is a malady of the moment. Throughout the centuries, people may have varied in their beliefs about the causes of depression, or what should be done about it, yet the actual descriptions of depression its key features and how it alters a person’s thoughts and behaviors show remarkable constancy. Something akin to our modern depression has existed throughout much of recorded history.
Written accounts of a condition similar to what we now know as depression appeared in the second millennium bc in Mesopotamia. One text described when a man had suffered a long spell of misfortune,
he shakes with fear in his bedroom and his limbs have become weak to an extreme degree; if he is filled with anger against god and king; and if he is sometimes so frightened that he cannot sleep by day or night and constantly sees disturbing dreams; if he is weak [from] not having enough food and drink; and if [in speech] he forgets the word which he is trying to say; then the anger of [his] god and goddess is upon him.
In these writings, depression was discussed as a spiritual rather than a physical problem (one that might be caused by demonic possession). One did not call a doctor; rather, one needed to hail a priest.
The ancient Greeks and Romans recognized melancholia, a condition that again appears akin to modern depression. For example, in Orestes, Euripides depicts the tragedy’s protagonist hounded by the furies after killing his mother. Orestes’ symptoms of depression resemble those of any modern suburbanite: loss of appetite, excess sleeping, lack of motivation to even bathe, constant weeping, chronic exhaustion, and a sense of helplessness.
Greek and Roman authorities on melancholia were split into different camps about its causes. Hippocrates’ take on melancholia, or a condition of the “fears and despondencies, if they last a long time,” was that it was a biological illness caused by an imbalance in four body fluids called humors: yellow bile, black bile, phlegm, and blood. Specifically, melancholia was attributed to an excess of black bile in the spleen. Hippocrates’treatments of choice to readjust the humors via bloodletting, baths, exercise, and diet. By contrast, Roman philosopher and statesman, Cicero, took another view of melancholia, seeing its roots in psychological events such as rage, fear, and grief. All the while, another great swath of opinion continued to believe that melancholy and other mental disturbances were caused by demons and by the anger of the gods.
In the Middle Ages, Christian religious views dominated European thinking on mental illness. Mental health problems such as depression were largely a sign of God’s disfavor, indicating a sinful life and/or a need for repentance. A sea change in thinking came with
Robert Burton’s 17th-century Anatomy of Melancholy. This widely read book offered a variety of explanations of melancholy, including more secular, social, and psychological reasons such as poverty, fear, and loneliness. Burton also included a number of nonreligious recommendations for treating it, such as diet, exercise, travel, purgatives (to clear toxins from the body), bloodletting, herbs, and music therapy. Even if depression cures such as purging or leeches now seem foreign, Anatomy’s descriptions of melancholy accord with contemporary psychiatry textbook descriptions of the psychology of the depressed person. Burton lays out an episodic,
melancholy which goes and comes upon every small occasion of sorrow, need, sickness, trouble, fear, grief, passion, or perturbation of the mind, any manner of care, discontent, or thought, which causes anguish, dulness, heaviness and vexation of spirit, any ways opposite to pleasure, mirth, joy, delight, causing forwardness in us, or a dislike.1
In the 20th century, the contemporary term depression gradually came into wider use. Many credit the pioneering 19th-century psychiatrist Emile Kraepelin for increasing the popularity of the word, as well as for the view that depression was due to brain pathology, which remains an important strand in mental health thinking to this day. At the same time, new ideas from Freud and his acolytes viewed depression as resulting from intrapsychic conflict (anger turned inward), a conflict that could be best addressed by talk therapy. To this day, biological perspectives on depression continue to coexist with a variety of psychological and psychosocial perspectives.
The 20th century also ushered in the more standardized diagnosis of depression that currently prevails. As part of a larger effort to handle mental illness similarly to biological diseases, psychologists and psychiatrists put together the first American Diagnostic and Statistical Manual of Mental Disorders (DSM) in 1952. In this first manual, which has since gone through several iterations, the term depressive reaction was used to describe a condition of severe low mood resulting from an internal conflict or an identifiable event such as job loss or divorce. In the DSM’s current incarnation, the principal place where depression is discussed is the syndrome major depressive disorder, which will become familiar later in this book.
Obviously, a Roman soldier, a Greek philosopher, a French peasant, and a New York City cabbie might have very different reasons for becoming depressed. And the authorities of the day would likely offer very different ideas about what each of these persons should do about it, from baths to bloodletting, exorcism, and Prozac. But in another sense, no matter where we turn in history, depression is depression. Each historical personage would likely experience similar symptoms and behave in similar ways, despite the wide gulfs of culture and language between them.
It is important to bear in mind that the evolutionary forces that sculpted our mood system move at a glacial, geologic pace. Evolutionary change is much slower than the pace of human events. Our world of airplanes, computers, and electricity presents us with an unimaginably different physical and psychological environment from what the first Homo sapiens faced 300,000 years ago, yet the nervous system that generates mood is basically the same as that of early H. sapiens. Because the architecture of our mood system cannot keep up with the furious pace of human events, different historical periods will trigger different
amounts of depression in the population (e.g., there is likely more depression in the United States now than in 1950), even as the essential form that depression takes remains the same. 1 Burton, R. (1621[2001]). The Anatomy of melancholy. New York: New York Review Books, 143.
THE SYNDROME OF CLINICAL DEPRESSION
What are the symptoms of depression?
Depression is a syndrome. A syndrome is a package of symptoms that group together in a nonrandom way. An example of a syndrome is a strep throat, where the package of symptoms might include a fever, bumps on the tonsils, pain in swallowing, and swollen lymph nodes. In this case, these symptoms package together because streptococcal bacteria have infected the body, prompting a cascade of responses. Confidence that these symptoms signal a genuine syndrome is high: Biological testing can verify the presence of the infectious bacterium as a causative agent.
By contrast, the syndrome of depression is not based on objective tests. Instead, it rests largely on observation of symptoms and on accumulated clinical wisdom. A variety of clinicians and researchers have noticed over time that certain psychological complaints are packaged together. Patients who complain of a low mood, for example, also tend to complain of fatigue and sleep difficulty. When enough of these symptoms co-occur, they can be diagnosed as the full depression syndrome, which is also called a major depressive episode. Ultimately, a depression diagnosis is founded on a careful assessment of a patient’s symptoms piecing together what the patient says, as well as how the patient is behaving. Although a clinician can filter or interpret the information provided by the patient, it is ultimately the patient’s report of symptoms that grounds a diagnosis rather than the state of their blood or brain.
So what are the symptoms of depression? I illustrate the nine symptoms of depression with the case of Lonnie, a 24-year-old freelance writer who has become depressed after the breakup of a long-distance relationship. Full disclosure: Lonnie is not a single identifiable depressed person. Like other cases presented in this book, she is a composite, sketched from the many interviews with depressed people I have conducted over the course of my research studies.
Cardinal symptoms
Two symptoms are considered so characteristic of depression that one or both are required for diagnosis:
A sad, low mood that the person can’t shake: Lonnie describes her mood as “hollow.” Most days during the past 3 months, she has felt empty or gloomy most of the time. Occasionally, her mood brightens for an hour or two, sometimes for no obvious reason. Unfortunately, these lighter periods don’t last.
A loss of interest or pleasure in things the person usually enjoys (which goes by the technical term anhedonia), which can apply to hobbies, friends, or sexual relations: Lonnie loves fashion and her professional writing covers the fashion industry, but since she has become depressed, she doesn’t open any of the glossy magazines or mail-order catalogues that she receives; these pile up unread on her coffee table. Her best girlfriends call her to make a date, hoping to cheer her up; she declines. Normally extroverted, Lonnie prefers now to keep to herself.
Associated symptoms
In addition to the cardinal symptoms, there are seven other associated symptoms of depression. A person must have at least five of the nine symptoms in total to be diagnosed:
Sleep problems: Sleep problems can manifest as an inability to fall asleep or stay asleep. The opposite pattern, sleeping much more than usual, is another possibility, but it is not as common. Lonnie’s case evidences classic insomnia: Every night she falls asleep like a ton of bricks only to wake up around 3 a.m., 4 hours before her alarm. Instead of falling back to sleep, she lies in bed ruminating on her failures, on what went wrong in her relationship, dreading the coming of the next day.
Problems with mental focus: This can appear as concentration problems or as an inability to make decisions. Lonnie struggles with her writing. She also detects that her mind is not working right when she finds herself in the grocery isle, paralyzed in front of a display, unable to choose which kind of sandwich bag to buy.
Changes in weight or appetite: The depressed person most typically will lose weight and eat less (due to depression, not an intentionally planned diet). Sometimes, depression can bring about the reverse pattern of increased weight or appetite. Lonnie had this symptom in a dramatic fashion. Previously a gourmet cook who loved food, she has dropped two sizes during the past 3 months and has to force herself to eat, often skipping meals. When asked about her appetite, she says, “These days I want to eat about as much as I want to clean the toilets.”
Fatigue or loss of energy: Depressed people typically state that they feel tired most or all of the time. Lonnie continually feels run-down. She has to rally herself to perform the most routine of tasks, such as taking her poodle for a walk around the neighborhood. She describes this tired feeling as like “the worst ever hangover,” without the fun of a party the night before.
Pathological guilt: The depressed person is often wracked by pervasive guilt about things that they have done or not done. Depressed people often come to doubt their fundamental worth as a person. Lonnie feels guilty for “being born”; in her mind, she continually goes over the ways she has been a terrible friend and a lousy daughter. She is haunted by the thought, “I am a waste of space.”
Psychomotor changes: Most typically, the depressed person talks or moves more slowly than normal. Some depressed people show the reverse pattern of agitation and restlessness. With Lonnie, her family and her therapist both notice that her speech is slowed; when she talks on the phone, her voice is a monotone; when asked a question, there are inexplicably long pauses before she responds.
Suicidality: Suicidality is the most frightening of depression’s symptoms. The depressed person may have general thoughts about the topic of death or specific thoughts of hurting themselves, which can lead to planning or attempting suicide. Lonnie’s case this manifests as a “passive death wish” as she drives on a two-lane highway, she wonders if it might be better if the oncoming car swerved in front of her.
Other common features
In addition to the previously discussed nine official symptoms, there are other behaviors that are also highly characteristic of depressed persons. Although they do not make the diagnostic manual as part of the recognized syndrome, they are very much worth noting:
Anxiety: Anxiety is like depression’s shadow. Most depressed people report elevated levels of anxiety. Lonnie is constantly on edge; her muscles feel tense; she worries constantly that she won’t get better and that she will lose her job and all of her savings.
Self-focused thinking: One of the most characteristic things depressed people do is to focus on themselves. Lonnie spends extended periods each day in solitary thought trying to understand why she is depressed; she keeps a journal in which she tracks her mood hour-by-hour and tries to connect any mood change to her activities and sleep. She dwells on her failings; she returns again and again to the idea that god or some unseen power might be punishing her by keeping her depressed.
Pessimism: Depressed people believe that the future will be worse than the present; it is a great struggle for them to maintain any degree of hope. Lonnie doubts that her antidepressant medications will be able to make her better; she doubts that she will be strong enough to survive her depression if it continues another 6 months. She is essentially one giant doubt. In her worst moments, she thinks to herself, “My life is over.”
Unexplained aches and pains: Depressed people commonly report physical complaints such as headaches, back pain, aching muscles, and stomach pain. One odd thing Lonnie noticed before she was diagnosed with depression was a pain on the left side of her chest; she worried something might be wrong with her heart, even though she was an athletic person in her 20s. After a medical workup, her family doctor could find no explanation for her chest pain complaint. Ultimately, this pain complaint would just be attributed to the depression, as yet another mysterious element of the condition.
Irritability: Depressed people often feel agitated, restless, and short-tempered. Lonnie has days where everything and everyone gets on her nerves. Sometimes she gets so charged up that she struggles to find a safe outlet for her furious rage; she is angry with her family, angry with her ex-boyfriend, angry with her dog, angry with the entire situation. She doesn’t scream and yell at those who have wronged her. She mostly holds it in, her main release going to her bedroom and punching into her pillows.
Self-medicating: Depressed people often struggle so much with their moods that they are (understandably) tempted to abuse substances to control them. Self-medication goes far beyond how patients might take liberties with their antidepressant drug prescriptions. It includes a variety of other substances chemicals that might be used to drown out pain or take the edge off anxiety. This includes drinking alcohol excessively, abusing opiates or sleep medications, or becoming addicted to anti-anxiety drugs such as Valium. For her part, Lonnie has become dependent on her sleep medications. Her pill stash is her dirty little secret. She is always experimenting with it; she hopes that if she takes the right amount of the drug at the right time, she will be able to sleep through the night. But this seldom happens; she instead ends up with the worst case poor quality sleep and feeling woozy the next day, slowed down by the aftereffects of the sleep medicine.
How is clinical depression different from a sad mood?
Clinical depression is diagnosed when patients report at least five of nine of the official
symptoms of a major depressive episode and when these symptoms are experienced for at least 2 consecutive weeks. Unfortunately, Lonnie is well in excess of these thresholds. However, we should recognize that the five of nine symptoms threshold for clinical depression is somewhat arbitrary. Arbitrary boundaries are common in many diagnostic thresholds for example, the exact number at which “high blood pressure” begins is more a convention than demarking a specific boundary of a disease.
The boundary for defining clinical depression, although important for guiding decisions, should not be considered completely absolute. Many people have troubling depression symptoms that fall short of the threshold for diagnosis. Imagine Chuck, who recently reports three depression symptoms: He has lost interest in activities, can’t sleep, and is experiencing constant fatigue. These symptoms cause him distress and hinder his work as a school principal. In clinical practice, people such as Chuck who have “subthreshold” symptoms of depression might be monitored for any worsening of their condition or they might be treated immediately, depending on the clinical judgment of the practitioner. Milder forms of depression are common, simply because all forms of depression are very common.
The existence of these milder forms of depression raises a larger question: How exactly is clinical depression different from “ordinary misery” or even a garden-variety sad mood?
In a key way, clinical depression is not different in kind from an ordinary sad mood. Clinical depression and ordinary sad moods are both products of the same mood system. Factors such as environmental stress or not getting enough sleep that render a person more vulnerable to clinical depression are the very same factors that render a person vulnerable to a garden-variety sad mood. From this perspective, the difference between clinical depression and an ordinary sad mood is just a matter of degree.
Even if it is made from the same building blocks as a sad mood, clinical depression can feel different to the sufferer. For one, clinical depression is stronger than a sad mood. States of clinical depression may be experienced as completely overwhelming. Clinical depression also lasts longer. Research that tries to map the typical duration of these states bears this out. Fortunately, ordinary sad mood will typically last hours or days. By contrast, the criteria for a major depressive disorder require a minimum 2-week duration, and typically, clinical depression lasts much longer, 4–6 months. The greater strength and duration of a clinical depression have real-world consequences for sufferers. As Lonnie’s mood deepened and as she could not stop it, she became ever more fixated on why she was feeling so bad and why she couldn’t shake it a self-sustaining cycle that further deepens her mood.
This underscores another potentially important difference, one that Lonnie notices, also typical of people who struggle with clinical depression: Clinical depression is more difficult to cope with than ordinary sad mood. When she experiences a normal sad mood, Lonnie can think of a dozen or more things she can do to cheer herself up, at least for a while. Watching her favorite show, eating a good meal, spending an evening with her girlfriends, spending half an hour at the gym, and even sometimes just taking a quick nap can all leave her feeling somewhat restored. By contrast, during her clinical depression, nothing she does seems to reliably lift her mood. For the past 3 months, Lonnie’s mood has basically been a brick wall, explaining her deep frustration, her loss of hope, and why she has become obsessed with every tiny fluctuation in her mood.
The distinct human experience of clinical depression is important to acknowledge: People who struggle with clinical depression often report that it “feels different” from an ordinary sad mood. This explains why people throughout history have perceived clinical depression in a strange and even frightening state. Lonnie, like many patients, says it’s difficult for her to put her finger on exactly what’s different, partly because it is so difficult to describe moods. She says that during her depression, rather than actually feeling sad, she feels “numb and cut off from my feelings, like I have an urge to cry but can’t.”
Finally, clinical depression, in part because it is stronger and lasts longer than ordinary sadness, creates far more impairment than ordinary sadness. A clinical depression can infer with people’s ability toto work, go to school, take care of their children, or maintain their relationships. In severe cases, the depressed person may be bedridden or fail to maintain personal hygiene. For Lonnie, the most notable impairment caused by her clinical depression was her inability to write. Normally, she could knock out a freelance assignment in a day or two. Her depression slowed her thinking and her writing to the point that just sitting at the keyboard and pecking out a few sentences became a struggle. She wanted to take a break from freelancing, but she had clients that were expecting finished stories and, frankly, she needed the money. This impairment also took an emotional toll: As deadlines came and went, Lonnie felt she was fundamentally incompetent, that no one would ever hire her again, and that no one ever should. Her case fundamentally illustrates how the different symptoms of depression can cascade and built upon one another.
How does clinical depression range in its severity?
To the previous point, we have been discussing how mood ranges from ordinary sadness to clinical depression. However, even after we cross the threshold into clinical depression, there is still considerable range left to cover. Clinical depression itself varies in its severity.
Patients with severe depression have typically well over five depression symptoms, and their symptoms are intense and impairing. For example, a patient with severe anhedonia may derive zero pleasure from any activity and be unable to conceive of anything that would give them pleasure in the future. Common patterns in severe depression include substantial weight loss and staying in bed for substantial periods of time because of a lack of motivation or energy. Typically, severe depression features dramatic alterations in a person’s behavior. Even basic hygiene such as showering, brushing teeth, or putting on clean clothing may be compromised. Likewise, in severe depression, cognition can be disturbed to the point of an outright break from reality. For example, a person’s feelings of guilt may be transformed into an unshakeable psychotic belief that the person is the devil. By contrast, in milder depression, a person may feel distress and may demonstrate more subtle alterations in cognitions and behaviors. At the same time, a person with mild depression may be able to function normally in many areas and may be concealing the symptoms from others for weeks or months at a time. In fact, people with milder depression may find that the condition subsides before they recognize a need for treatment or before they get help.
Perhaps not surprisingly, extensive research demonstrates that severity of symptoms is an important basic characteristic of depression. Generally speaking, more severe depressions are
more challenging to treat; they tend to last longer than mild or moderate depressions and are more likely to recur.
What is the difference between unipolar depression and bipolar disorder?
In discussing depression, this book focuses on unipolar depression, the more common group of the mood disorders. The uni in unipolar depression is what it sounds like. People with unipolar depression have one set of problems; these problems lie exclusively at the low pole of mood, encompassing the sorts of depression symptoms we have been discussing. By contrast, people with bipolar disorder have problems at the high pole of mood. The high pole in bipolar disorder involves periods of what are called hypomania or mania; these are mood episodes in which people experience abnormally elevated or euphoric or sometimes irritable mood, along with associated symptoms such as racing thoughts and a tendency to pursue dangerous or risky activities. Although it may sound like fun to have abnormally elevated moods, the highs of bipolar disorder can be quite destructive, with people spending their life savings, abusing drugs, and making other poor life choices.
People with bipolar disorder most typically have two sets of mood problems. In addition to problems at the high pole of mood, periods of depression, at the low pole of mood, are also characteristic. Bipolar disorder can be particularly treacherous to cope with, as a person oscillates between the plunging lows of depression and the soaring highs of mania or hypomania. Signs of this difficulty, the classic forms of bipolar disorder, are associated with both high rates of hospitalization and high rates of attempted and completed suicide.
Bipolar mood disorders are different from unipolar depression in a number of other ways. First, the psychology differs. Because bipolar disorder also involves abnormal highs, it can be even more of a confusing roller coaster than unipolar depression, both for the person directly affected and for the person’s family. Treatments for bipolar mood disorders also differ. Most important, a class of drugs called mood stabilizers, the best known of which is lithium, are used to try to even out the highs and lows of bipolar disorder. In fact, many in psychiatry express concern that traditional antidepressants can aggravate or worsen mood instability in a person who has a bipolar mood disorder. Some researchers also believe that bipolar disorders are more strongly controlled by genetic risk than are unipolar mood disorders. Because of these many differences, diagnostic systems such as the Diagnostic and Statistical Manual of Mental Disorders, fifth edition, traditionally separate depressive disorders and bipolar mood disorders in different sections. For these reasons, our knowledge about unipolar depression may not apply well to bipolar disorders. Specific resources for persons with bipolar mood disorders are included in the Resources section.
WHEN SHOULD I WORRY THAT I MIGHT BE DEPRESSED?
Case Study: Jose
What’s wrong with me? Five months ago, Jose asked that primal question. The first odd thing he noticed was being as weak as a kitten just walking up a flight of stairs left him totally drained. Not only was Jose tired and run down, his thinking was fuzzy. Reading a policy memo, he kept going over the same paragraph. He felt unwell. Was it the flu, he wondered, or could it be depression?
At first, he discounted the possibility. Did he really have reason to be depressed? Yes, he was often harried at his job as a health policy analyst, but other things in his life were going just fine. He had a mostly good marriage; he owned his own home. He was fortunate to have close friends. Turning 50 maybe stirred some midlife anxiety, but his health to this point had been okay. His feelings didn’t totally compute. How could I be depressed when most of my life was going okay? As the weeks rolled on, he decided, “It’s just job stress.” It was more comfortable to believe depression was a label that didn’t apply to him.
But the feelings didn’t pass. After 2 months of further struggle, Jose decided he had to see a doctor to get to the bottom of his symptoms. He emerged from the appointment with a diagnosis of depression and a slip of paper with a name of a drug scribbled on it. A week into the medication, he was waiting for the pills to work their magic.
Depression doesn’t always trumpet its presence when it visits a person. This is in part because there’s no bright line between the ordinary “blahs” and the syndrome of clinical depression. So, when is it reasonable to worry that you or your loved one may be facing the serious possibility of clinical depression? Here are some clues:
Strong and durable symptoms: As noted in Chapter 2, clinical depression is stronger and lasts longer than ordinary sadness. Although ordinary sadness can move one to tears, depression more fully takes over the body and mind. For example, Jose felt physically weakened, and he was not able to focus his attention on his work. Likewise, experiencing a low mood for a day or a week, with or without a reason, is consistent with ordinary mood variation. Jose’s low mood went on for months relatively uninterrupted a worrisome pattern. Depression has an insistence and a persistence to it that ordinary sadness does not.
Difficulties functioning: Depression involves a more significant change in functioning than does ordinary sadness. Usually when people are sad, they can still do their work, relate to others, and take care of life’s mundane business. It is reasonable to worry about clinical depression if mood impairs any of these major life domains. In Jose’s case, he now struggled to write the policy memos that usually came so easily for him. He started to avoid his friends and acquaintances, and he stopped exercising, previously a joy and an outlet.
Feelings are out of scale with the situation: Another warning sign that something more than simple sadness may be afoot is when environmental events cannot explain the depths of the person’s feelings. It’s natural to have a period of sadness after being snubbed by a friend or when your favorite sports team loses a title. Major losses such as the death of a close family member will trigger more significant depressed mood (including the possibility of clinical levels of depression). In Jose’s case, he discounted the possibility that he could be depressed because there were no clear events that could explain his feelings. That’s actually a misconception because clinical depression does not require a trigger. In fact, careful studies of life events demonstrate that many people who are diagnosed with depression do not report any obvious trigger event beforehand.
The possibility of clinical depression is, understandably, unsettling or frightening for many. Some are scared by the associations of a diagnosis: Could it mean you are a “crazy person” who has “lost their mind”? Others, unfortunately, continue to hold the outdated view that a mental health diagnosis signifies a personal failing. Still others recoil from diagnosis because they are afraid of contact with the mental health system (“I’ll be given medications against my will or put in a straitjacket”). Such attitudes explain why Jose like many people may want to attribute depression symptoms to something such as run-of-the-mill job stress. Fear of diagnosis and a reluctance to enter treatment may help explain why surveys find that more than half of people who meet diagnostic criteria for depression do not use treatment services. Jose’s case also illustrates another way depression is often undertreated: Even when people enter treatment, that entry comes only after a lag after depression has run unchecked.
Can I self-diagnose?
If you’ve read to this point, you’ve learned about the symptoms of depression. As a book-
reading, savvy person, you’re likely to also know that there are tests you can take on the internet that profess to reveal whether a person has depression. You may wonder: Why even go to a treatment professional? Why not just take a free test and self-diagnose?
You certainly can self-diagnose, and for people who have had extensive experience with depression (i.e., many previous episodes), self-diagnosis might be reliable. For everyone else, a self-diagnosis of depression is error prone and may provide a seriously incomplete picture. A segment of depression self-diagnoses will be false-positive errors (making a diagnosis when it is not merited). False-positive errors occur because sometimes things are, in reality, not as bad as they seem in our minds. Some people are temperamentally anxious or are just prone to see the worst in themselves, leading to an exaggerated report of symptoms. For such individuals, a clinician’s careful, independent assessment of symptoms may reveal that the concerned person is well short of a depression diagnosis. In such cases, a professional’s assessment may provide some reassurance. If treatment for depression is not yet indicated, contingency plans can be made in case symptoms worsen.
Self-diagnoses of depression can also produce false-negative errors (missing a diagnosis that is present). Some people (like Jose) may be motivated to mask the true severity of their symptoms; denial of our problems is a common human foible. At other times, people miss symptoms because they lack knowledge about depression or because they lack self-insight. In all such cases, the value of a careful, thorough, independent clinical assessment is that it corrects for such biases and can discover the reality of a diagnosable depression, even when this is not what the person “wants to hear.”
The errors of self-diagnosis are often magnified by the self-tests that are used. In the past 20 years, the information that had exploded on the internet is akin to a new Wild West. Selftests on depression, and on other mental health conditions, have proliferated with virtually no regulation. Consequently, it is easy to “click” on many depression tests or screenings on the internet and be blissfully unaware that the questions you are answering are not from a validated instrument. Of course, use a poor test and erroneous results are more likely. Fortunately, some self-tests do use validated instruments. For example, when the search term “depression” was used on Google, U.S. users were directed to a depression test in the top group of results, and the search engine commendably used the Patient Health Questionnaire9 (PHQ-9) a short instrument that has at least demonstrated prior validity. A published study showed that if you have a high score on the PHQ-9, odds are fairly good that a clinician would independently find you to be diagnosable with depression. Even with the best of these self tests, however, we are straining their purpose by asking them to provide a “yes” or “no” answer on diagnosis. Remember that these tests were originally intended to be used for screening, not as stand-alone tests to render a diagnosis of depression by themselves. I make these points not to denigrate people’s curiosity about themselves or to discourage people from visiting credible health-oriented websites that are geared for the consumer (e.g., WebMD and Healthline). Indeed, these websites often present solid information about depression, and using such resources is beneficial when it helps people become more informed about the condition or find appropriate treatment resources. But the trend toward self-diagnosis, in part fueled by such websites, also has a dark side. For example, selfdiagnosis may paradoxically play into treatment avoidance. As more people hold an
