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Dealing with Depression

A Common Sense Guide to Mood Disorders

Allen & Unwin

WHAT IS DEPRESSION?

Depression is a disorder of mood ... [which] remains nearly incomprehensible to those who have not experienced it in its extreme mode, although ... 'the blues' ... give many individuals a hint of the illness in its catastrophic form.

William Styron, Darkness Visible

The term 'depression' means different things to different people. All of us, at one time or another, have felt depressed, whether over bad news, a day-to-day problem or even for no reason at all. This is described as normal depression, or a normal depressive mood state. It may be experienced as a 'blue' mood, a drop in self-esteem or self-value, increased self -criticism, a lack of pleasure in life, feelings of wanting to 'give up' and pessimism about the future. Such feelings are not usually held at great depth, are transient (usually lasting only minutes to a few days) and are not disabling.

A person suffering from clinical depression holds these mood state features with more conviction than someone experiencing normal depression. The mood state and associated symptoms (described on pages 2 — 4) will nearly always have been present for more than two weeks and are associated with both social and psychological disability.

A representative list of features of depression is given below, some of which indicate particular depressive disorder subtypes (expanded on in later chapters).

Thus, somebody with depression may experience:

• Lowered self-esteem — that is, a loss of normal self-confidence, feelings of worthlessness and inadequacy, or guilt. Pessimistic and self-critical thoughts are common.

• Change in sleep patterns — that is, insomnia, or broken or fitful sleep. Some people might get off to sleep at the normal time, but wake at 2 — 3 a.m. and then either not get back to sleep or sleep fitfully, waking up several more times during the night. Others may take hours to fall asleep, or sleep fitfully all night.

• Change in mood control. Although the word 'depression' suggests that mood is always 'down', during a depressive episode all moods tend to be hard to control. Some people may feel unduly miserable and pessimistic, crying for little reason, and not feel any better after a good cry. Others may have difficulty controlling anger, flying off the handle at the slightest provocation. Irritability may be high, often followed by self -reproach and guilt. Anxiety can also get out of control and 'mountains made out of molehills'; worrying may become excessive. Some people develop panic attacks.

• Change of mood through the day ('diurnal variation'). Some depressed people feel most depressed in the morning and improve as the day goes on, while others experience the reverse pattern, or no mood variation at all.

• Change in appetite and weight. This may take two forms. In some people, especially if older, appetite may be reduced and weight lost. Constipation can also be a problem. However, for others, appetite and weight may increase. This pattern occurs especially in people who feel needy and respond to cravings for sweet foods by bingeing or by drinking more alcohol than usual. Many people crave cigarettes when depressed. These behaviours are not always psychologically driven. As detailed later, some may reflect biologically adaptive responses that redress the neurotransmitter changes underpinning the depressive condition.

• Change in capacity to experience and anticipate pleasure. Typically, hobbies and interests 'drop off'. People suffering from this symptom, termed anhedonia, 'just can't be bothered' to do the things that previously gave them pleasure.

• Change in the ability to tolerate pain. Physical pains that are normally bearable may seem to get worse, or pains that cannot be readily explained by a physical problem may be experienced. This is because some types of depression actually lower the pain threshold, while other depressive conditions cause physical symptoms (e.g. headaches, chest pain, stomach churning) as well as pain.

• Change in sex drive. Libido is commonly reduced or absent. Occasionally, there is an increase in 'needy' sex, perhaps because depression impairs the capacity to feel close to a partner.

• Suicidal thoughts. It is common to feel that there's just no point in going on. This may extend to thoughts of death, as well as to vague or specific suicidal thoughts or plans.

• Impaired concentration and memory, causing some people to believe they may be 'dementing' or going mad. These intellectual functions return to normal when the depression is relieved.

• Loss of motivation and drive. Everyday activities may seem meaningless.

• Increase in fatigue, feeling tired and lacking in energy. Some people may also find it hard to concentrate and may feel 'slowed down'.

• Change in movement. Some depressed people become physically slow or even immobile and experience slowed thinking ('retardation'). Conversely, others may become more agitated and be unable to sit still, with excessive and persistent worrying causing profound mental stress. In some cases retardation may alternate with agitation. Such obvious movement irregularity is called 'psychomotor disturbance', or PMD.

• Psychotic features. A small percentage of people suffering depression may develop delusions (false beliefs such as 'I am totally worthless', 'I am so guilty, I should be punished') and/or hallucinations (hearing voices and seeing things that are not there). Some people may note changes in their hearing and their sense of smell (often such senses are sharpened) or changes to taste (e.g. food tastes metallic).

• Disability. Clinical depressive conditions are associated with disability, or impaired function. Unipolar depression has been identified as the most disabling disorder and bipolar disorder the sixth most disabling. Disability clearly stops a lot of people from going to work, but it is interesting to note that a greater economic burden comes from people getting to work but not being able to function effectively at work.

False positives

While all the mood state features listed above may indicate depression, most by themselves do not. For example, changes in sleep patterns can be attributed to a number of reasons. Older people generally require less sleep. Sometimes, early morning waking indicates a weak bladder or a snoring partner. Being stressed commonly disrupts sleep. Sex drive is liable to be reduced when there are relationship problems.

Changes in mood control could be the result of excessive use of alcohol or drugs, or a reflection of personality style. Anxiety and panic attacks often occur separately from depression, while changes in appetite and weight could be due to other medical conditions or a result of medication, stress or grief.

DEPRESSION, A COMMON EXPERIENCE

Depression is referred to as 'the common cold of the psyche'. Most people will experience episodes of normal depression. However, 25 per cent of women and 20 per cent of men will experience episodes of clinical depression during their lifetime. Having a depressive episode is therefore commonplace and certainly no cause for shame.

What is a shame is that clinical depressive disorders are so often undiagnosed and untreated (or undertreated). This sometimes happens because of the fear of disgrace associated with depression; or because doctors or health professionals don't recognise depression for what it is. It can also occur because individuals do not recognise their own depression. Depression may come on as a conviction that this is the way the world is or, more indirectly, physically as a series of illnesses, aches and pains.

Some clinical depressive disorders seem to run in families, with family members prone to depression, or mood swings, in the same way that other families have a tendency to stomach ulcers, diabetes or migraines. However, for many people there is no family history of depression.

If the depression is minor or transient, it may resolve by itself and not require any intervention. If it is more intrusive and persistent, professional help should be sought. When the disorder becomes intractable and debilitating, specialist treatment is required.

Those who don't respond to initial treatment may require expert review. Some people need to try several antidepressant medications, while others need to try quite different non -medication approaches. Such varying choices sometimes reflect the general preference of the treating therapist, rather than a more logical, commonsense approach that respects the importance of identifying and addressing the specific cause. At other times, the outcome reflects the nature of the differing depressive disorders, or the fact that the ideal or best treatment is not identifiable.

Research at our Institute suggests four principal causes of persistent and treatment-resistant mood disorders: 1. undertreatment of the more biological conditions such as melancholic depression; 2. excessive physical treatments for those with the less biological (e.g. non-melancholic) depressive disorders; 3. failure to diagnose bipolar disorder; 4. failure to identify an underlying contributory condition (whether medical or another psychiatric condition such as an anxiety disorder).

Each of these issues will be discussed shortly, and each underlines the importance of ensuring that the depressive subtype is identified.

Remember that depression can be biological in its origin, but psychological in experience. Those suffering from depression may have to push themselves or be encouraged by someone else to seek advice or treatment. They may feel that nothing much can be done about the way they feel but, in fact, most acute depressive disorders can be successfully treated.

The purpose of 'normal depression'

For most people, depression (even the commonly occurring normal depression) is an unpleasant experience that often interferes with day-to-day functioning.

What is the purpose of such a painful experience? This question can be linked to another one: What is the purpose of pain? Pain has one distinct advantage — the unpleasant side effects of pain mean that most of us will go to considerable lengths to avoid it. For example, if we did not find heat painful, we might get too close to a fire and suffer the consequences. It is for such reasons that many nerves in our bodies have heat receptors.

In a similar way, it could be argued that normal depression can be an automatic defence response or a response cued by certain situations. Such a proposition has been explored by the American psychiatrist Randolph Nesse (2000) whose thesis is considered below. He looks particularly at how normal depression may have offered a selective advantage to civilisation over time. To the extent that any of Nesse's interpretations have validity, they allow the individual to question the meaning of a 'depressed mood' — what is normal depression trying to say?

Is normal depression a cry for help?

It is unlikely that normal depression is a cry for help. If it is, then it is not a very useful or effective signal, as it is more likely to evoke negative responses from others.

Does depression help to conserve resources?

If someone is lethargic, has no appetite, lacks motivation and has no interest in conversation, might not such a state resemble hibernation in the animal world and be a way of conserving energy?

Nesse argues that depression is 'poorly designed' for such a purpose — at least in humans. The argument might hold for animals, where an animal continues to forage for as long as there is an adequate food source. But, when the food source runs low and the animal has to use up more energy foraging than would be obtained from eating the food, it would be wiser for the animal to stand still — even if starving — and wait for some other food source to turn up. It would stretch credibility to suggest that depression has such an advantage for humans.

Can depression resolve competition with a dominant figure?

Is depression a signal to a more 'powerful' competitor that a threat no longer exists (thus ending the conflict and the depression)? Does it represent a true wish on the part of an individual to resolve a conflict and obtain reconciliation, or is depression designed to lull the competitor into a false sense of security? Again, while of clear relevance to animals, its pertinence to humans can be questioned.

Can depression help us to be more realistic in goal setting?

If a particular goal (e.g. a new partner, or a new job) is starting to look like 'mission impossible', somebody in a depressed mood state may feel compelled to reassess the situation before disengaging from the pursuit or escaping from the situation. To persist with a goal that looks unattainable requires considerable increase of effort from the normal, everyday pace of life and, if the goal is not achieved, the resultant depression will be even greater.

The argument is, then, that a depressed mood drives people away from tasks that will be unprofitable, or a waste of effort or dangerous. Failure to reach, or to renounce, a goal may be depressing in the short term, but the negative cost or pain may be less than the costs and pain of persevering with the task. If a setback occurs in pursuit of a major goal, it would make sense not to rush into chasing another significant goal. In such instances, moving into a depressive state (with symptoms such as pessimism and lack of initiative) might, as Nesse (2000) notes, 'prevent calamity even while it perpetuates misery'.

Conclusions

There are several limitations to the interpretations considered by Nesse. First, they appear more relevant to animals than humans. Second, their benefits in contemporary society are not obvious. Even if true, such theorising is likely to have relevance only to normal depression and perhaps to some forms of non-melancholic depression.

The answer is perhaps best addressed at the individual level. Consideration of their own patterns of behaviour might prove more useful to a depressed person, especially when the episode is over. Questions that could be asked include:

• In what circumstances do I find myself getting depressed?

• What then is the message?

• Do I want to do anything about it?

Thus, while relief from depression may require treatment for some individuals, others may obtain more benefit from rearranging their 'ecological niche' or modifying their work and family systems to prevent the grating factors that may be lowering their sense of self -worth and driving the pain of depression.

In both normal and non-melancholic depression, some elements of the disorder may have homeostatic capacities, helping the body to return to normal. Thus, sleeping excessively (as many depressed individuals do) may be an adaptive behaviour by restoring slow -wave sleep during times of stress. Carbohydrate cravings and eating chocolate, in particular, have comforting effects that trigger the release of endorphins to create a 'feel good' state. Eating more of certain foods may lead to an increase in the amine L -tryptophan, thus increasing the activity of serotonergic neurotransmitters in the brain, which may be disrupted during depression.

Just as a pregnant woman may develop an aversion to cigarettes and alcohol because of potential damage to the foetus, some people may lose pleasure in drinking alcohol during their depression. And while some people may no longer be interested in smoking, others develop a craving for tobacco (which might then increase the level of the brain neurotransmitter, dopamine, which may be decreased in some depressive disorders).

Thus, some symptoms in the less biological types of depression may be a response to painful psychological and social life situations; others may be adaptive attempts at normalising disturbed biological changes.

For the more biological types of depression, such as melancholia, it is difficult to believe that such disorders are primarily adaptive or functional responses. The British satirist and writer Spike Milligan observed:

I cannot reassure myself that it has been worthwhile ... I do not hold with this romantic view of depression, that it has some purpose ... As far as I am concerned it is without a redeeming feature. (Milligan & Clare 1999: 41)

By contrast, the academic psychologist and expert in mood disorders Kay Jamison has stated (1995) that, if given the choice as to whether or not she would have manic-depressive illness, she would change nothing. If she had not had the disorder, she would not have:

felt more things, more deeply; had more experiences, more intensely ... laughed more often for having cried more often; appreciated more the springs, for all the winters ... Even when I have been most psychotic — delusional, hallucinated, frenzied — I have been aware of finding new corners in my mind and heart.

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Excerpted from Dealing with Depression by Gordon Parker. Copyright © 2004 Gordon Parker. Excerpted by permission of Allen & Unwin.
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