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What is depression?

If you suffer from depression, you are, sadly, far from being alone. In fact, it has been estimated that there may be over 350 million people in the world today who have it. Depression has afflicted humans for as long as records have been kept. Indeed, it was first named as a condition about 2,400 years ago by the famous ancient Greek doctor Hippocrates, who called it ‘melancholia’. It is also worth noting that although we cannot ask animals how they feel, it is likely that they also have the capacity to feel depressed: they can certainly behave as if they do. To a greater or lesser degree, we all have the potential to become depressed, just as we all have the potential to become anxious, to grieve or to fall in love.

Depression is no respecter of status or fortune. Indeed, many famous people throughout history have had it. King Solomon, Abraham Lincoln, Winston Churchill and the Finnish composer Jean Sibelius are well-known examples from history. What is important to remember is that depression is not about human weakness.

What do we mean by ‘depression’?

This is a difficult question to answer, because a lot depends on who you ask. The word itself can be used to describe a type of weather, a fall in the stock market, a hollow in the ground and, of course, our moods. It comes from the Latin deprimere, meaning to ‘press down’. The term was first applied to a mood state in the seventeenth century.

If you suffer from depression, one thing you will know is that it is far more than just feeling ‘down’. In fact, depression affects not only how we feel, but how we think about things, our energy levels, our concentration, our sleep, even our interest in sex. Depression has an effect on many aspects of our lives. Let’s look at some of these.

•   Motivation. Depression affects our motivation to do things. We can feel apathetic and experience a loss of energy and interest, nothing seems worth doing. If we have children, we can lose interest in them and then feel guilty. Each day can be a struggle of having to force ourselves to perform even the smallest of activities. Some depressed people lose interest in things. Others keep their interest but don’t enjoy things when they do them, or are just very tired and lack the energy to do the things they would like to do.

•   Emotions. People often think that depression is only about low mood or feeling fed-up – and this is certainly part of it. Indeed, the central symptom of depression is called ‘anhedonia’– derived from the ancient Greek meaning ‘without pleasure’– and means the loss of the capacity to experience any pleasure. Life seems empty; we are joyless. But – and this is an important ‘but’ – although the ability to have positive feelings and emotions is reduced, we can experience an increase in negative emotions, especially anger. We may be churning inside with anger and resentment that we can’t express. We might become extremely irritable, snap at our children and relatives and sometimes even lash out at them. We may then feel guilty about this, and this makes us more depressed. Other very common symptoms are anxiety and fear. When we are depressed, we can feel extremely vulnerable. Things that we may have done easily before seem frightening, and at times it is difficult to know why. We can suddenly feel anxious at a bus or shop queue or even meeting friends. Anger and anxiety are very much part of depression. Other negative feelings that can increase in depression are sadness, guilt, shame, envy and jealousy.

•   Thinking. Depression interferes with the way we think in two ways. First, it affects concentration and memory. We find that we can’t get our minds to settle on anything. Reading a book or watching television becomes impossible. We don’t remember things too well, and we are prone to forget things. However, it is easier to remember negative things than positive things. The second way that depression affects our thoughts is in the way we think about ourselves, our future and the world. Very few people who are depressed feel good about themselves. Generally, they tend to see themselves as inferior, flawed, bad or worthless. If you ask a depressed person about their future, they are likely to respond with: ‘What future?’ The future seems dark, a blank or a never-ending cycle of defeat and losses. Like many strong emotions, depression pushes us to more extreme forms of thinking. Our thoughts become ‘all or nothing’ – we are either a complete success or an abject failure.

•   Images. When we are depressed, the imagery we use to describe it tends to be dark. We may talk about being under a dark cloud, in a deep hole or pit, or a dark room. Winston Churchill called his depression his ‘black dog’. The imagery of depression is always about darkness, being stuck somewhere and not able to get out. If you were to paint a picture of your depression, it would probably involve dark or harsh colours rather than light, soft ones. Darkness and entrapment are key internal images.

•   Behaviors. Our behavior changes when we become depressed. We engage in much less positive activity and may withdraw socially and want to hide away. Many of the things we might have enjoyed doing before becoming depressed now seem like an ordeal. Because everything seems to take so much effort, we do much less than we used to. Our behavior towards other people can change, too. We tend to do fewer positive things with others and are more likely to find ourselves in conflict with them. If we become very anxious, we might also start to avoid meeting people or lose our social confidence. Depressed people sometimes become agitated and find it difficult to relax. They feel like trapped animals, restless, pace about and can’t sit still, wanting to do something but not knowing what. Sometimes, the desire to escape and run away can be very strong. However, where to go and what to do is unclear. On the other hand, some depressed people become very slowed down. They walk slowly, with a stoop, their thoughts seem stuck, and everything feels ‘heavy’.

•   Physiology. When we are depressed there are many changes in our bodies and brains. There is nothing sinister about this. To say that our brains work differently when we are depressed is really to state the obvious. Indeed, any mental state, be it a happy, sexual, excited, anxious or depressed one, will be associated with physical changes in our brains. Recent research has shown that some of these are related to stress hormones such as cortisol, which indicates that depression involves the body’s stress system. Certain brain chemicals, called neurotransmitters, are also affected. Generally, there are fewer of these chemicals in the brain when we are depressed, and this is why some people find benefit from drugs that allow them to build up. The next chapters will explore these more fully. Probably as a result of the physical changes that occur in depression, we can experience a host of other unwanted symptoms. Not only are energy levels affected, so is sleep. You may wake up early, sometimes in the middle of the night or early morning, or you may find it difficult to get to sleep, although some depressed people sleep more. In addition, losing your appetite is quite common and food may start to taste like cardboard, so some depressed people lose weight. Others may eat more and put on weight.

•   Social relationships. Even though we may try to hide our depression, it almost always affects other people. We are less fun to be with. We can be irritable and find ourselves continually saying no. The key thing here is that this is quite common and has been since humans first felt depressed. We need to acknowledge these feelings and not feel ashamed about them. Feeling ashamed can make us more depressed. There are various reasons why our relationships might suffer. There may be conflicts that we feel unable to sort out. There may be unvoiced resentments. We may feel out of control. Our friends and partners may not understand what has happened to us. Remember the old saying, ‘Laugh and the world laughs with you. Cry and you cry alone’? Depression is difficult for others to comprehend at times.

•   Brain states. A useful way to think of depression, then, is that it is a change in ‘brain states’. In this altered state, many thing are happening to your energy levels, feelings, thoughts and body rhythms. There are many reasons for this change in brain state that we call depression, and there are many different patterns that are linked to depression, as we will see. But the key thing is to recognize there has been a change in brain state, and your thoughts and feelings are linked to that. It is very important not to blame yourself for the difficulties that this depressed brain state makes for you, but rather work out what will help you shift it – and that is what we will be exploring in this book.

Are all depressions the same?

The short answer to this is no. There are a number of different types. One that researchers and professionals commonly refer to is called ‘major depression’. According to the American Psychiatric Association, one can be said to have major depression if one has at least five of the possible symptoms listed in Table 1.1, which have to be present for at least two weeks.

I have included this list of symptoms here to give you an idea of how some professionals tend to think about depression. Although a list like the one in Table 1.1 is important to professionals, it does not really capture the variety and complexity of the experience of depression. For example, I would include feelings of being trapped as a common depressed symptom, and many psychologists feel that hopelessness, irritability, and anxiety are also very central to depression.

Researchers distinguish between those mental conditions that involve only depression and those that also involve swings into mania. In the manic state, a person can feel enormously energetic, confident and full of their own self-importance, and may have great interest in sex. If the mania is not too severe, they can accomplish a lot. People who have swings into depression and (hypo)mania are often diagnosed as suffering from bipolar illness (meaning that they can swing to both poles of mood, high and low). The old term was manic depression. Those who only suffer depression are diagnosed as having unipolar depression.

Another distinction that some researchers and professionals make is between psychotic and neurotic depression. In psychotic depression, the person has various false beliefs called delusions. For example, a person without any physical illness might come to believe that he or she has a serious cancer and will shortly die. Some years ago, one of my patients was admitted to hospital because she had been contacting lawyers and undertakers to arrange her will and her funeral as she was sure that she would die before Christmas. She believed that the hospital staff were keeping this important information from her to avoid upsetting her, and she tried to advise her young children on how they should cope without her (causing great distress to the family, of course). Sometimes people with a psychotic illness can develop extreme feelings of guilt. For example, they may be certain in their minds they have caused the Iraq war, or done something terrible. Psychotic depression is obviously a very serious disorder, requiring expert help but, compared with the non-psychotic depressions, it is quite rare.

Another distinction that is sometimes made is between those depressions that seem to come out of the blue and those that are related to life events, e.g., when people become depressed after losing a job, the death of a loved one or the ending of an important relationship. However, in psychotherapy, we often find that, as we get to know a person in depth, what looks like a depression that came out of the blue actually may have its seeds in childhood.

Clearly some depressions are more serious, deep and debilitating than others. In many cases, depressed people manage to keep going until the depression eventually passes. In more serious depression this is extremely difficult, and getting professional help is important. Depressions can vary in terms of onset, severity, duration and frequency.

•   Onset. Depression can have an acute onset (i.e. within days or weeks) or come on gradually (over months or years). It can begin at any time, but late adolescence, early adulthood and later life are particularly vulnerable times.

•   Severity. Symptoms may be mild, moderate or severe.

•   Duration. Some people will come out of their depression within weeks or months, whereas for others it may last in a fluctuating, chronic form for many years. ‘Chronic depression’ is said to last longer than two years, and 10–20 per cent of depressed people have it.

•   Frequency. Some people may only have one episode of depression, whereas others may have many. About 50 per cent of people who have been depressed will have a recurrence.

The fact that depression can recur may seem alarming, but this should really come as no surprise. Suppose, for example, that since a young age you have always felt inferior and worthless. One day this sense of inferiority seems to get the better of you and you feel a complete failure in every aspect of your life. Perhaps a drug will help you to recover from that episode, but even if you become better, you may still retain, deep down, those feelings of failure and inferiority. Drugs do not retrain us or enable us to mature and throw off these underlying beliefs. Therapies are now being developed to help prevent relapses.

How common is depression?

As indicated, depression is, sadly, very common. If we look at what is called major depression, the figures are:

	Women	Men
	(per cent)
Having depression at any one time	4–10	2–3.5
Lifetime risk	10–26	5–12

The figures are even higher in some communities (e.g., with poverty). Moreover problems such as eating disorders, drug and alcohol problems and aggressiveness can also be linked to depression, and recede as depression is treated. New research also indicates that rates of and risks for depression have been steadily increasing throughout the twentieth century, but the reasons for this are unclear. Socio-economic changes, the fragmentation of families and communities, the loss of hope in the younger generation – especially the unemployed – and increasing levels of expectations may all be implicated.

In general, then, there are many forms of depression – in fact, so many that the term itself is not so helpful. But it is important to recognize that not all depressions are the same and they can vary greatly in severity and duration.

KEY POINTS

•   Depression is very common and has been for thousands of years.

•   Depression involves many different symptoms. Emotions such as anger and anxiety are common and at times more troubling than the low mood itself. People who are depressed may also have a strong desire to escape, for which they may feel guilty.

•   There are many different types of depression.

•   Some depressions are quite severe, while others are less so but still deeply disturbing and life-crippling.

If you suffer from depression, my key message to you is that if you feel a failure, if you have a lot of anger inside, feel on a short fuse; if you are terrified out of your wits, if you think life is not worth living, if you feel trapped and desperate to escape – whatever your feelings – these reflect your brain state, are not your fault, and millions of others have these feelings too. Of course, knowing this does not make your depression any less painful, but it does mean that there is nothing bad about you because you are in this state of mind. It is a shift in brain state that is painful – depression pulls us into thinking and feeling like this, so these feelings are sadly part of being depressed. True, some people who have not been depressed may not understand it, or may tell you to pull yourself together, but this does not mean that there is anything bad about you. It just means that they find it difficult to understand.

Importantly, there are many things that can be done to help us when we get depressed so a key message is: ‘please talk to your family doctor.’ There are some helpful (for some people) drugs (antidepressants) available and many effective psychological treatments. We can learn to train our minds to shift us out of depressed brain states. This is covered in Parts II and III.