Chapter Nine

WHAT IS CLINICAL DEPRESSION, AND HOW DO I KNOW IF I HAVE IT?

“Depression is an illness. I am sick. I need to be here not because I'm defective, not because I am a moral leper, not because I've fallen from grace or turned my back on God, but for one simple reason: I am sick.”

–Tracy Thompson, The Beast

Before we can begin the better mood program we need to first take a look at what we will be treating—the syndrome of depression. This chapter will provide you with an overview of the causes and symptoms of clinical depression.

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The voice on the phone did not sound like the Jesse I knew. The tone was flat and tentative, the usual confidence visibly absent.

I'm not doing so good,” he mumbled.

“What's going on?”

“I'm having a hard time keeping up in my first term at college. I just can't seem to concentrate on my studies.”

“That seems odd. You were so motivated to do well in high school.”

“I know. But I just don't have the energy I used to. My sleep is messed up. I wake up in the middle of the night with my mind racing and spinning and I can't get back to sleep. In the morning, I can't seem to get out of bed to get to class. Sometimes I wonder if it's all worth it.”

Such talk was uncharacteristic of my nephew who had been an honor roll student throughout high school. Two weeks later I received the following email. “Blackness, darkness, the walls are closing in. It won't be long, now.” I called Jesse's dad. The next day we withdrew Jesse from the university, and escorted him to the crisis triage center at Providence Hospital in Portland, Oregon.

“It's major depression, isn't it,” I said to the resident psychiatrist.

“How did you know?”

“I just experienced my own episode last year,” I replied. “Once you go through a hell like this, you never forget it.”

As we enter the twenty-first century, Jesse and I are far from being alone. Depression has now become the second most disabling condition in the world (surpassed only by heart disease) and the fourth most disabling worldwide. The disorder does not discriminate among its victims—it affects all age groups, all economic groups, and all gender and ethnic categories. While the average age of onset was once a person's mid-thirties, it is now moving toward adolescence and even early childhood. At any given moment, somewhere between 15 and 20 million Americans are suffering from depressive disorders, and about one in five will develop the illness at some point during their lifetimes.

The first step in becoming liberated from the mental straightjacket of depression is to recognize and understand the nature of the condition. Getting proper help for depression begins with proper diagnosis. The purpose of the pages that follow is to provide a clear understanding of the signs and symptoms of major depression so that you can determine if you or a loved one may need to seek treatment.

What Is Clinical Depression?

A depressive illness is a “whole body” disorder, involving one's physiology, biochemistry, mood, thoughts and behavior. It affects the way you eat and sleep, the way you think and feel about yourself, others and the world. Clinical depression is not a passing blue mood or a sign of personal weakness. Subtle changes in the brain's chemistry can create a terrible malaise in the body-mind-spirit that can affect every dimension of your being.

 

The Depression Cycle

Depression manifests as a complex interaction between one's thinking, physiology, mood, and behavior, as depicted in the diagram below.

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Depression is called the “common cold” of mental illness, not because its symptoms are mild but because the disease is so widespread across cultures. It is the most diagnosed mental health disorder in the United States, among the most debilitating, and the most lethal (15 percent of all untreated clinical depressions result in suicide). According to an estimate in the Journal of Clinical Psychiatry, each year depression accounts for a $43.7 billion burden on the American economy, as measured in medical costs, lost productivity in the workplace and at home, and lost contributions of wage earners who die from depression-related suicide.

Although depression has become the malaise of our times, it has plagued humankind since antiquity. King Saul of the Bible (who needed David's music to soothe his despondency) was a classic depressive. The Greeks were the first to understand the biological nature of depression and gave it the name “melancholia” (from the roots “melaina chole,” meaning “black bile). In the 17th century, English scholar Robert Burton wrote the definitive work of the era on the subject—The Anatomy of Melancholy.

Though depression is a serious illness, it is highly treatable, as it normally responds to a combination of antidepressants and psychotherapy. Unfortunately, the majority of people with depression do not seek treatment because the symptoms are unrecognized, misdiagnosed, because the individual is deterred by the stigma surrounding mental illness.

What are the Symptoms of Depression?1

Depression is a complex disorder and its symptoms express themselves on many levels. Depression creates physical problems, behavioral problems, distorted thinking, changes in emotional well being, troubled relationships and spiritual emptiness. The symptoms of major depression can be divided into three categories:

1) disturbances of emotion and mood.

2) changes in the “housekeeping” functions of the brain—those that regulate sleep, appetite, energy and sexual function.

3) disturbances of thinking and concentration.

The most common symptoms of clinical depression include:

In the workplace, depression can be recognized by the following symptoms:

For those who are at home, these symptoms may appear as:

In order to best apply this cluster of symptoms to your own situation, think of your symptoms in terms of three words—number, duration and intensity.

1) Number. The symptoms of depression are “additive”—that is, the greater the number of symptoms you have, the more likely you are to be clinically depressed. According to the Diagnostic and Statistical Manual of Mental Disorders (DSM IV), five or more of these symptoms should be present for a person or someone close to that person to consider him or herself “clinically depressed.”

2) Duration. The longer you have been down in the dumps, the more likely it is that you are clinically depressed. According to the DSM IV, the five or more symptoms must exist for at least two weeks for a diagnosis of major depression to be made. (In the case of dysthymia or chronic low-grade depression, symptoms must be present for two years or more.)

3) Intensity. Many of us can feel emotional pain and still cope with our daily existence. Some experiences of depression are within the normal course of living. The pain of major depression can be so great, however, that its intensity (along with the number and duration of symptoms) can significantly impair one's ability to cope.

Getting proper help for depression begins with proper diagnosis. Of the 17 million people who suffer from depressive illnesses, over two thirds (about 12 million) receive no treatment whatsoever. The minority who do seek help typically consult a number of doctors over many years before the proper diagnosis is made. The questionnaire that follows may help you to determine if you suffer from depression.

 

Diagnostic Criteria for a Major Depressive Episode

A depressive illness is a “whole body” illness, involving one's body, mood, thoughts and behavior. It affects the way you eat and sleep, the way you feel about yourself and think about things. It is not a passing blue mood or a sign of personal weakness.

Depressive illnesses come in different forms, the most serious of which is major depression. The following criteria for major depression are taken from the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). If you or someone you know fits these criteria, seek professional help.

A. Five or more of these symptoms should be present during the same two-week period and represent a change from previous functioning.

  1. Depressed mood most of the day.
  2. Markedly diminished interest in pleasure.2
  3. Significant change in appetite, leading to weight loss or weight gain.
  4. Insomnia or hypersomnia (too much sleep) nearly every day.
  5. Psychomotor agitation or retardation nearly every day.
  6. Fatigue or loss of energy nearly every day.
  7. Feelings of worthlessness or excessive or inappropriate guilt.
  8. Diminished ability to think or concentrate, or indecisiveness.
  9. Recurrent thoughts of death, recurrent suicidal thoughts without a specific plan, suicide attempts, or specific plans for committing suicide.

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

 

Self-Rating Scale for Depression

Have either of the following symptoms been present nearly every day for at least two weeks?

A. Have you been sad, blue, or “down in the dumps?”

B. Have you lost interest or pleasure in all or almost all the things you usually do (work, hobbies, interpersonal relationships)?

If either A or B is true, continue. If not, you probably do not have a depressive illness. Now continue by answering the following statements:

Have any of the following symptoms been present nearly every day for at least two weeks?

1. A poor appetite or overeating?

 No Yes

2. Insomnia—trouble falling asleep, or nighttime awakenings?

 No Yes

3. Oversleeping (going to bed a lot earlier than usual, staying in bed later than usual, taking long naps)?

 No Yes

4. Do you have low energy, chronic fatigue or do you feel slowed down?

 No Yes

5. Are you less active or talkative than usual?

 No Yes

6. Do you feel restless or agitated?

 No Yes

7. Do you avoid the company of other people more than you used to?

 No Yes

8. Have you lost interest or enjoyment in pleasurable activities, including sex?

 No Yes

9. Do you fail to experience pleasure when positive things occur—such as being praised, being given presents, etc.?

 No Yes

10. Do you have feelings of inadequacy or decreased feelings of self-esteem, or are you overly or increasingly self-critical?

 No Yes

11. Are you less efficient or do you accomplish less at school, work or home?

 No Yes

12. Do you feel less able to cope with the routine responsibilities of daily life?

 No Yes

13. Do you find that your concentration is poor and that you have difficulty making decisions (even trivial ones)?

 No Yes

14. Do you think and/or talk of death and suicide?

 No Yes

15. Have you at any time in the past been acting unusually happy for more than two weeks?

 No Yes

If A or B is true and if you answered yes to five or more of the above questions, you may have a major depressive illness. If you answered yes to #15, you may consider whether major depression is but one phase of a bipolar disorder.3

For the diagnosis to be complete, however, you should have a complete physical exam and blood workup to rule out other medical problems such as anemia, reactive hypoglycemia and low thyroid, all of which cause symptoms which may mimic those of major depression. Specifically, you will want a test of the thyroid function called the TSH (thyroid stimulating hormone) stimulation test as well as the TRH (thyrotropin releasing hormone) stimulation test. (The TRH test is complicated to perform and is thus rarely ordered by doctors; however, it can pick up on thyroid disorders that the TSH test cannot.).

What Are the Different Type of Depression?

We began this chapter by stating that getting proper help for depression begins with a proper diagnosis. This is easier said than done, since depression, like the mythological Hydra, is a many-headed beast. There are many types of depressive disorders, each of which contains a multitude of symptom patterns and representations. Here is a list of most common depressive disorders as listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV).

In this chapter we have focused on the most common depressive disorder, clinical depression. The remaining depressive disorders are described in detail in Appendix A.

What Occurs in the Brain of a Depressed or Anxious Person?

Just as coronary heart disease is a disorder of the circulatory system and diabetes is a disorder of the pancreas, depression and anxiety are disorders of the brain. When people become severely depressed or anxious, the brain literally becomes “sick,” although no one knows precisely how. This is because the brain is both inaccessible (it is surrounded and protected by our thick skulls) and incredibly complex—possibly the most complex structure in the known universe. At birth, an infants brain contains 100 billion nerve cells, called neurons—a quantity that rivals the number of stars in the Milky Way. But when we marvel at this complexity, we are not just talking about the sheer numbers of the cells. Rather, it is what these cells do. Unlike other cells in the body—a muscle cell, fat cell or liver cell for example—the neurons of the brain and nervous system carry on complex conversations with one another. Each one of these billion neurons carries on thousands of conversations with its neighbors. Consider the challenge of being on the phone and talking with 1,000 or 10,000 people simultaneously, and trying to keep all the conversations straight. In depression, these conversations get disrupted, with catastrophic consequences.

 

Images of Depression

Depression is a unique malady that is extremely difficult to put into words. Perhaps the best way to convey the actual experience of depression is through image and metaphor. Here is a sample of apt descriptions taken from those who have been there.

 

Anatomy of a Neuron

The diagram below depicts the four parts of a nerve cell—the cell body, the axon, the dendrites and the synapse—the space between one nerve cell and the next.

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There are two areas of the brain that are believed to be affected in clinical depression. The first area is the space between the cells, known as the synapse. In these spaces we find chemical messengers known as neurotransmitters that allow the nerve impulses to be fired from one cell to the other. There are two neurotransmitters that have been specifically to mood disorders—serotonin and norepinephrine. Originally it was thought that too little of these messengers existed in the synapses between the nerve cells, and that antidepressants restored the right amount by preventing them from being reabsorbed into the brain cells. Recently, this theory has been discarded as being too simplistic, and attention has been turned to other theories of what is going awry.

 

The Limbic Brain

The hypothalmus and amydala are two parts of the emotional brain that have been implicated in depressive and anxiety disorders.

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The second aspect of the brain that is affected by mood disorders is the limbic system, also known as the emotional brain. The limbic system is the mediator of human feelings. It receives and regulations emotion, governs sexual desire, and, through a walnut sized gland called the hypothalamus, oversees the smooth running of the physical body's “housekeeping functions”—thirst, appetite, sleep, as well as pleasure, sexual desire and aggression. These, of course, are the precise activities that get thrown out of whack in depression.

 

Healthy Sadness vs. Depression

Many people confuse depression with sadness. While intense sadness may be a component of depression, depression is a whole body disorder that contains many other dimensions of imbalance and dysfunction. The chart below contrasts these two states.

Characteristic of Healthy Sadness Characteristics of Depression
1. You are sad, but don't feel a loss of self-esteem. 1. You feel a loss of self-esteem.
2. Your negative feelings are an appropriate reaction to upsetting events. 2. Your negative feelings are out of proportion to the event that triggered the bad mood.
3. Your feelings go away after a period of time. 3. Your feelings continue and do not let up.
4. Although you feel sad, you do not feel discouraged about the future 4. You feel demoralized and are convinced that things will never get better.
5. You continue to be productively involved with life 5. You give up on life and lose interest in your friends and your career.
6. Your negative thoughts are realistic 6. Your negative thoughts are exaggerated and distorted, even though they seem valid.

 

Finally, the amygdala, an almond-like structure in the limbic system, has been implicated in anxiety disorders. The amygdala controls the brain's fear reaction. For example, if I were walking the street and spotted a bear, the amygdala would send signals to my brain to begin the fight or flight response which would increase breathing, heart rate, blood pressure, etc. Panic attacks and phobias are disorders of this fear system when the amygdala gets activated, even when there is no apparent threat.

What are the Causes of Depression?

For many decades, a bitter argument has been raging in the psychiatric community between those who feel that the causes of depression are genetic and biological illness and those who feel that they are psychological and social. Fortunately, an increasing number of clinicians are subscribing to the “fertile ground” theory, which says that “depression is a genetic disorder of the mind-body-spirit which occurs when predisposing factors combine with environmental stressors.

In other words, for clinical depression to occur, two factors are ususally present:

1) Biochemical or physical predisposition (which provides the fertile ground)

2) A triggering stressor, which brings on the actual episode. (There are times, however, when an episode can mysteriously begin “out of the blue.”)

Predisposing factors

A predisposition to clinical depression can be caused by a variety of genetic, biochemical, and environmental factor:

Kagan believes that these babies were simply born with different brain chemistry.4

Neuroscientist Richard Davidson has confirmed Kagan's research by demonstrating in his laboratory that the low reactive children have pronounced activation in a region of the brain called the left prefrontal cortex and less activity in the amygdala (the brain's fear mechanism). Conversely, Davidson has found that depressed, unhappy people have more activity in the right prefrontal cortex of their brains (not the left), and have especially overactive amygdalas.

Environmental Triggers

Now that we have looked at the genetic/biochemical causes of depression, let's turn our attention to the environmental ones. Environmental factors include.

 

Anxiety/Depression Symptoms Inventory

The following questions are designed to help you to better understand your history and symptoms of depression so that you can better treat them. You can answer in the spaces provided or on a separate sheet of paper. You may also wish to purchase a journal in which to record your answers to this and the other questionnaires that will appear in this book.

1. Is there a history of either depression or anxiety in your family? Name any relatives that suffered from these disorders.

2. Researchers at Harvard have identified the “inhibited, high reactive child” who is more likely to be shy, reserved, fearful and pessimistic. How closely did you childhood temperament match this description?

3. Can you identify any early childhood stress or trauma (i.e. loss, abandonment, abuse, neglect, etc.) that increased your likelihood of becoming depressed or anxious as an adult?

4. Write down what you consider the most prominent symptoms you experience during times of depression or anxiety (refer to the symptom lists on pages 118-121.

1.

2.

3.

4.

5. Once a person is vulnerable to depression, it usually takes an external trigger or stressor to elicit symptoms. What in the past (or in the present) have been the events, thoughts or feelings that triggered your feelings of anxiety or depression?

6. Depression is epsiodic and cyclic. If you have had a previous episode of depression, what were the events and circumstances that helped bring you out of it?

7. If you are currently in the middle of an episode of depression, how does knowing that you have emerged from previous episode help to reassure you that “This, too shall pass?”

 

Biology Is Not Destiny

The fertile ground theory tells us that although environmental factors play an important role in mood disorders, people do not suffer from serious episodes of depression and anxiety without a biochemical predisposition. Does this mean that we are doomed by our genes and temperament? Not necessarily, says Jemome Kagan:

For example, if a “high reactive” infant is raised in a good environment by great parents, is good in school, and has lots of friends, then this child will not end up unhappy, but relatively happy. It's just that he's got to fight the bias. Remember, if you're born with a gene that says you're going to be 6 foot 9, then your biased to be a great basketball player. But there are some short men who are great basketball players. They overcame their bias. And that's true for everything in life.5

Other neuroscientists concur with Kagan. Joseph Ledoux, the scientists at New York University who has done pioneering work on anxiety and the brain, says, “The brain has plasticity, the ability to rewire itself in response to environmental stimuli and any kind of learning.” Scientists now know that neurons in many parts of the brain continue to undergo structural change not just through childhood and adolescence but through all of life. These scientific discoveries are life-changing, for they tells us that we are no longer a helpless victims of our genes and or biochemical make-up. No matter how many episodes of depression and anxiety you have suffered (or are suffering), your brain and nervous system can be rewired and reprogrammed. This is what we will be seeking to accomplish in our better mood recovery program.

1 Much of the information about the symptoms of depression was provided by the Depression Awareness Recognition and Treatment program (D/ART) of the National Institute of Mental Health. Call (800) 421-4211 for free literature, or visit their Web site (www.nimh.nih.gov).

2 Perhaps the single most defining symptom of depression is the loss of pleasure. In the words of neuroscientist Robert Sapolsky, “If I had to define depression in a single sentence, I would describe it as “a genetic-neurochemical disorder requiring a strong environmental trigger whose characteristic manifestation is an inability to appreciate sunsets.”

3 Adapted from Donald Klein and Paul Wender, Understanding Depression, New York, Oxford University Press, 1993, pp. 13-15.

4 When I first encountered Kagan's work, I was astounded to see how the “high reactive” temperament so accurately portrayed my personality as an infant and young child. It also removed some of my guilt and shame by making me realize that I did not create my basic temperament—i.e., it was not my fault that I was born with a predisposition to depression.

5 From the cassette, “Gray Matters: Emotions and the Brain,” by the Dana Alliance for Brain Initiatives, 1-800-65BRAIN