The subject of Depression is mired in misconceptions about what a depressive disorder 'is' and its 'causes', which may create uncertainty in choosing appropriate treatment. As we all aim to help people with depression, and their loved ones and carers as well, achieve a better quality of life, it's crucial to explain the development of depression, its physical symptoms and its effects on emotional and mental health. Hence, any informative discussion requires some clarification.
- Depression is not a 'mental illness' or 'psychiatric disease'. DSM (Diagnostic and Statistical Manual) classifies depression as a 'mood disorder' or 'affective disorder'.
- 'Stigma' is an arbitrary 'us and them' distinction perpetuated by the media.
- Depression is regarded as a 'lifelong disease' and any respite merely 'remission' between episodes. BIOLOGICAL depression tends to be recurrent, but PSYCHOLOGICAL depression is recurrent only if both the 'episode triggers' and underlying 'vulnerability factors' are not addressed in treatment.
- Depression is said to be 'caused' by lack of mood regulating neurotransmitters in neural synapses. This causal assumption is based on antidepressant medication ability to alleviate depressed mood by making neurotransmitter available in the synapse (increases production or blocks re-uptake). However, neurotransmitter function has been found to return to normal after psychological therapy – without medication. So, the appropriate question is, "What interferes in neurotransmitter function?" Stressful life events can interfere with numerous body processes and likewise, can interfere in normal neurotransmitter function. Hence, lack of neurotransmitter is merely the 'intermediary mechanism', not the actual 'cause' of depression symptoms.
Types of Depression
i) Two main classifications
'Endogenous-BIOLOGICAL' (Melancholia, Psychotic Depression, Bipolar Disorder) is severe depression accounting for 10% of cases and 'Exogenous-PSYCHOLOGICAL' (reaction to a 'catastrophic event' or 'depressogenic circumstances', generally with pre-existing underlying 'vulnerability factors' from childhood 'stuff') accounting for 90%.
ii) Atypical Depression
Typically, the depressed person experiences appetite loss and weight loss. But with Atypical Depression, there is craving for high-calorie food. This results in weight gain, which has a detrimental impact on physical health. However, Atypical Depression is not a separate subtype of depression. It is PSYCHOLOGICAL and the food craving/eating is not merely a common symptom but is actually 'comfort eating' for 'self medication'. Therefore, this type of depression requires treatment addressing 'depressogenic situational factors' and the underlying 'vulnerability factors' responsible for 'comfort eating' as a coping strategy.
iii) Postnatal Depression
PND, also known as postpartum depression, is not a mystery subtype of a major depression that 'randomly' attacks new mothers, although it may seem so when victims are 'strong' or 'competent' women. It can be BIOLOGICAL but in general, is PSYCHOLOGICAL so there are generally pre-existing 'vulnerability factors'. Normally, this 'stuff' is kept 'under wraps' and the woman functions and enjoys life, but the vulnerability to experience depression is ever-present if at some time in her life, she finds herself living in a 'life trap' or 'depressogenic circumstances'.
Life changes due to the birth of a baby and perhaps hormonal imbalances provide the 'precipitating event' for the symptoms of depression to show up. Evidence that the pre-existing factors exist lies in advice given to ante-natal care professionals to be 'alert' for signs of PND risk. Treatment may require medication to take the edge off the depression so the new mother can function, but the main treatment needs to be psychological therapy to address the pre-existing 'vulnerability factors' and issues around the 'changed life situation'. Too often, women are medicated indefinitely, for years, even being medicated needlessly after the depression has remitted.
Grief is not depression, but a natural process coming to terms with serious loss (death of a loved one or loss of something valued). Time does heal, pain eases and life can become enjoyable again. However, grieving twelve months later is 'complicated grief', which presents as depression. The grieving process is 'stuck' due to unresolved emotional issues in regard to the 'departed' (e.g. feelings of guilt, regret, shame, anger). Normal healing can proceed by addressing these emotional issues.
Effective Treatments for Depression
In the treatment of depression in mainstream medicine, 'first line' treatment is medication (ie antidepressant and maybe a 'mood stabiliser' or anti-psychotic as an 'adjunct'). Medication is limited in effectiveness since it only 'manages' the condition of depressed people by addressing the symptom of 'depressed mood'. BIOLOGICAL depressions do need medication, while a severe form, such as PSYCHOLOGICAL depressions, may benefit from medication initially, to 'take the edge off' so a patient can function.
NB: Coming off medication must be gradual withdrawal under medical supervision.
Psychological therapies have historically been regarded in psychiatry as having a 'complementary' or 'adjunctive' role in depression when medication has failed to achieve a satisfactory outcome. However, psychological therapies are 'stand alone' treatments for PSYCHOLOGICAL depression, which is a 'manifestation' of the actual problems: (i) long term 'vulnerability factors' (underlying unresolved emotional issues, coping style, childhood 'stuff') and (ii) current/ongoing 'depressogenic circumstances'. Those with BIOLOGICAL depressions can benefit since they harbour 'vulnerability factors' and experience 'life stressors'. Depression will sometimes 'spontaneously remit' because the 'precipitating event' has 'resolved itself' or the person experienced a 'lightbulb moment' of awareness and clarity.
'Outside the box' Theory
Depression is 'psychological pain' with a role analogous to 'physical pain', which warns of 'physical injury or malfunction in the body' requiring 'attention'. Likewise, 'psychological pain' warns of 'emotional injury or malfunction of the psyche' that needs 'attention'!