Depression

Frequently people mistake depression for other problems and think they are depressed when they are merely sad, down or lacking in some physiological way. Depression is a significant life affecting disorder that is more than just transitory. Sometimes depression has the pre-word “clinical” to help differentiate it from when people feel down and misidentify themselves as being depressed. There are things you can do to address depression including lifestyle change, medication and cognitive therapies. People diagnosed with depression of a significantly higher likelihood to suicide.

Diagnosis

First of all, let us define depression. Depression is a clinical diagnosis given to people who find their emotions depressed, find they are despondent, are amotivational (without motivation), and or lacking in energy to the point of incapacity. According to the DSM V (the Diagnostic and Statistics Manual 5, formed in the USA):

“A. Five (or more) of the following symptoms have been present during the same 2- week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure.
Note: Do not include symptoms that are clearly due to a general medical condition, or mood-incongruent delusions or hallucinations.
• Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad or empty) or observation made by others (e.g., appears tearful). Note: In children and adolescents, can be irritable mood.
• Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation made by others).
• Significant weight loss when not dieting or weight gain (e.g., a change of more than 5 percent of body weight in a month), or decrease or increase in appetite nearly every day. Note: In children, consider failure to make expected weight gains.
• Insomnia or hypersomnia nearly every day.
• Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down).
• Fatigue or loss of energy nearly every day.
• Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick).
• Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others).
• Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.

B. The symptoms cause clinically significant distress or impairment in social, occupational or other important areas of functioning.

C. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hypothyroidism).” – DSM V

Let’s pull that apart a little. First of all, there need to be some significant symptoms in multiple categories – physical, psychological and ontological. At least one of the symptoms needs to be a depression of mood or joy. These symptoms should not be due to another aspect of a different disorder. For example, a negative trait (a trait missing from most people) of schizophrenia can be anhedonia, an inability to find or feel joy. Because it is part of the diagnosis for schizophrenia , it should not also be used to also diagnose depression (but only, in this case, if you are diagnosed with schizophrenia).

Secondly these symptoms have to be significant enough that they are causing distress in your life. Significant is measured externally by the effect the symptoms are having on your social interactions, necessary work or another major, externally measurable effect. When we humans have an emotional reaction to something, we can easily misperceive a molehill as a mountain. Other external people may not see it the same way. Internal psychology is hard to measure, but the effect of what we are feeling on our lifestyle is quite easy to measure. This gives an objective measure to severity via the impact it has on our day to day existence. This does not mean to belittle how horrid we feel, it just contrasts it to how well we cope or manage. Each human has traits (happy, sad, guilty etc). When a trait becomes an extreme it generally becomes a problem and we change its classification to a clinical disorder.

Thirdly these symptoms cannot be caused by a physiological disorder such as nutritional deficiency (vitamin D or B12, iron etc), a side effect of medication, or some other specific biological disorder such as a hypothyroidism (where the thyroid doesn’t produce enough of certain hormones). When all of these factors are considered, what is left is a disorder that is debilitating and isn’t caused by the presence of another substance, isn’t a deficiency in nutrition and isn’t caused by another diagnosis.

Depression is a description of symptoms, but not of causes. Exactly what is the source cause for depression is not really known. Some fMRI (functional Magnetic Resonance Imaging) scans of peoples brains have shown suppressed activity in areas generally associated with joy and happiness, others have lower levels of serotonin or serotonin re-uptake inhibitors in their brains and some have all the signs and symptoms with nothing showing in any of the tests. Yet they are all labelled as depression even though it is thought that each of these has variable causes. As medical knowledge advances, this will get teased out and specific causes will be identified which lead to specific treatments. Until then, the simple method of treating depression is to brute force attack (that is systematically try the best combinations) the known treatments.

Medication

The most common first step is to start on some antidepressants. There are a host of common ones that work on the most common forms of depression. These drugs are directly targeting the chemistry in the brain for the most common things that are out of balance that lead towards depression. Because each person is different, different forms of the medication may have a greater or lesser affect on an individual.

Balance comes in three flavours:

  • Excessive neuro transmitters, which need to suppressed.
  • Deficit transmitters, which need to be boosted.
  • Errors in the cycling of the transmitters, which need correction.

People can have a combination of two or more of the above. Keep in mind, this is a vastly simplified explanation.

Even if two people have the same form of depression caused by the same problem, their differences in weight, gender, genetics, diet and lifestyle can affect the efficacy of taking the same drug. Some find that one brand works better than another, or that an alternate pharmacological method of eliciting the same end result (such as increasing the amount of serotonin) is more efficient, or that the dose needs to be higher or lower to get the same results. In summary, the first medication you go on may not be affective, and it will most likely need to be tweaked to get the best results.

Medication works well for roughly 1/3 of people diagnosed with depression. Initially it allows them to get back on track with how their lives were before the depression hit (if it is a recent thing), or find their lives if they never experience a depression free life (lifelong depression is fairly rare, but can happen). It is not intended as a solo solution.

For another 1/3 of people diagnosed with depression, it has some positive effect, but is not enough to get back to the old life (or for some a new life). This might be because the right combination hasn’t been found, or the symptoms are being caused by a combination of both chemical imbalance and poor psychosocial patterns. More on this later in the section about changing your life.

For those who are doing the maths, you will note that roughly 1/3 of people are left – they experience no positive effect of the medication. For them, this seems like a massive waste of time, each time hoping for being saved, only to have the hopes dashed when a few weeks later the medication again has no positive result. This is both true (as described) and false, because you are missing the bigger picture. There is no easy method of measuring if you are going to be responsive to medication or not until you try and are successfully – or not. Also medication should not be given in isolation, it should be coupled with non pharmacological therapies. And lastly you have now ruled out a treatment method that won’t be effective for you.

All medications have listed side effects. A side effect is an effect the medication can have on a percentage of the people who take it that is not the primary effect desired from the medication. Side effects are fairly minimal and generally safe, or vary rare if unsafe – else the medication would not be allowed for public use for long. It is important to know what the side effects can be so that if you are affected you know that the likely cause of the effect is the medication you are on. Report to your treating doctor the side effects (if any) you experience. Sometimes these side effects are rough and make being on medication worse than not being on medication. This is not common, although you will hear a great deal of people talk about it, giving a distorted prevalence of this via their poor confirmation bias. Basically the vast majority of people who have no significant side effects don’t talk about all the lack of side effects, so you only hear the occasional squeaky wheel in the dark and assume that all wheels are squeaky.

Cognitive Therapies

There are a number of cognitive therapies that are available for depression. Cognitive therapies rely on a person being able to analyse their existing behaviour patterns (sometimes with help), identify positive and negative patterns, then adjust their lives to promote positive patterns and address negative patterns. This doesn’t work for people who lack the insight needed to analyse the patterns, or people who are unwilling to change their lives.

Many people think that talking to someone is stupid and ineffective, a sign of weakness, or exposing themselves to scrutiny and judgement. There is an element of truth to this, but it’s the wrong angle.

  • Stupid and ineffective – If you are talking to someone that you don’t connect with, or is not qualified to help you then you make no progress and you resent the discussion. You don’t have to be pally with the therapist, but you need to feel a level of trust in your discomfort. Discomfort is actually a good thing, but terror is not. Often people lie to their therapists and that just doesn’t help at all. The qualification of your therapist is important. While there are some naturally good conversationalists, having a plan on how you are going to work collaboratively on your problems to overcome and defeat them takes training. Anyone can call themselves a therapist or counsellor – so beware of what actual qualifications the practitioner actually has.
  • A sign of weakness – it is a sign of weakness. If you were able to help yourself, you wouldn’t need help. You need help. Avoiding admitting you need help by avoiding therapy is like admitting you are falling from a plane and refusing to pull the cord on the parachute, as if that last step is going to stop you from the nasty end you are heading to. Dramatic, I know. But really, go talk to some professional.
  • Exposing yourself to scrutiny and judgement – this is absolutely true. If you aren’t willing to examine yourself in front of someone who can help you, why are you there at all? The point is to examine and jointly judge what is working, what is not and discover what needs to change. The fear is that the therapist will judge that you are faulty, a failure, a horrid person and so on. Generally the therapist will see that you are someone who needs help to make it on your own, the rest doesn’t matter. Even if they do see you as those things, isn’t that why you are there? To get help to not be that any more?

It is important that you develop a comfortable relationship with your therapist. This is referred to as “rapport”. It is a professional relationship built on trust and a desire to achieve a goal – your independence. If you can’t trust your therapist, then find someone you can trust. The therapist is not your friend, they are your employee. Unless you are court mandated to work with the therapist, you can always chose another (with the minor exception of small towns – and even then, if you have the internet or phone, you have access to more).

There are three main components to therapy:

  • Identifying and understanding the problem
  • Making change
  • Evaluating the change

A lot of therapy gets stuck in the first or last stage and forgets the middle. Also keep in mind it is not a linear thing – you don’t just do the three steps and you are “cured”. You repeat with your therapist until you can do this on your own.

Changing Your Life

If you don’t make changes in your life, then you won’t make any changes in your life. It amazes me how such a simple sentence can sum up the power you have in your life and your future. There are four main components you can manipulate about your life and they are summed up in four categories.

  • Biological
  • Psychological
  • Social
  • Spiritual

I have written about this before. In short:

Biological – may mean taking medication, doing exercise, managing your sleep cycle, changing your diet and or change in your weight. Without your body motor running efficiently, how can you work with your feelings and motivation? It’s like trying to hammer a nail into wood with a twisted nail and a broken hammer.

Psychological – This is about working out your patterns and modifying them. Patterns include how we perceive our environment, how we react to things, our habits and tool kit of coping mechanisms and strategies.

Social – Humans are social animals and we need to factor in our interaction with others. Do we have friends, and if so do we like them and do they bring out the best in us? Who are the professionals in our life and what are we using them for – is their a plan to become independent of them? Do you hide from people or just pretend while around them? Who do you turn to when you need help and how are they coping – is it just one or many?

Spiritual – We live in a world of people, animals, plants and things. Without any of these life is not possible. We are influenced and influence other things. How we see ourselves in this mix is vital to our health. When we forget our importance (and we are all important), then we diminish our worth in our own priorities and stop doing things like eating, doing activities, seeing friends and so on. When we stop doing these things, we stop living. It is only a matter of time before we stop being alive. It is vital to rediscover our worth, not only in our own eyes, but in the eyes of others. It is easy to hide from the system and be missed – but you are so much more than that. You can make a difference, and it is a good difference.

Examine each of these things – judge yourself against them, identify some things (no more than 3 at a time) that you are going to work on, define what basic step you can take to adjust these and how to tell if it has succeeded. Then, most important of all, act. Do it.

Suicide

People who are depressed are 10-2o times more likely to suicide than those who have no diagnosis (or could be diagnosed). While this sounds horrid, it isn’t quite as scary as it seems. Most people who are depressed do not suicide, but many people who suicide are depressed. That’s statistics for you. We still need to look at suicide square in the face though.

There are three major types of suicide.

  • Hopeless suicide
  • Angry suicide
  • Accidental suicide

Hopeless suicide is attempting to end the pain. The victim has concluded that this is the only escape because nothing can help. This is the last ditch escape from an intolerable situation. They have lost their self worth and have succumbed to the belief that there is no way out. Often this is hallmarked by gifting self identified meaningful things to those who they think were good to them or they cared about. It is important to get help before this happens, because it is not true. Just because you can’t see a way out doesn’t mean there isn’t one, hence why you get help to find a way.

Angry suicide is generally sending a message to others. Most depressed people do not have the energy to maintain enough anger to suicide for this reason. There is a danger when people start on medication and begin to get better. They still see the horror of depression but now have the energy to do something about it. This is a crucial time to seek strategies to hold on until the medication has a stronger effect and you pass this danger point.

Accidental suicide usually comes from those who are calling for help. Calling for help is a method of externalising the internal pain, frequently through self harm (cutting, substance abuse, self harming sexual relationships, financial harm etc), or “suicide attempts” that are timed for people to find them. Either the self harm goes to far, or the people didn’t come, or didn’t come on time. These behaviours are an attempt to get people to see that help is needed and to invite them in to do so. It is better to ask directly than to use these methods, or to identify that this is what is happening and get help to manage.

As an aside, it is frequently the wrong thing to go cold turkey (total cessation) on self harm. The idea is to introduce harm minimisation strategies around this safety valve, change your life so you no longer need the safety valve, then delete the self harm.

Suicidal ideation is talking and or thinking about suicide without actually enacting any further steps to achieve suicide. We humans always consider options and given grim times some of those options are unpleasant. Contemplating suicide can be a powerful incentive to change, or to feel like we do have a choice – “I could always kill myself – aka I choose to be alive”. Flirting with the idea of suicide is a good time to get some counselling. When the flirtation with the idea becomes planning, this is a good time to call suicide help lines for help and go and see your doctor.

Every major country has suicide prevention numbers (Australia Life Line – 13 11 14), talk to your therapist, and talk to your general doctor. Once you have a strategy, involve key friends. Generally friends are not trained to help with suicide and it is better to get professional help.

Conclusion

Depression is a diagnosis that is given due to a significant negative impact to an individual’s lifestyle. It describes a life that is quite literally depressed from what would be commonly expected. Most depression is treatable with a combination of medication, therapy and lifestyle changes. Many people recover from depression while some people manage it. While suicide is an important consideration in conjunction with depression, it is not inevitable and has well researched methods to address it too.