Depression – the Human Aspects

Chances are that if you are looking up this information on depression you are concerned about yourself, a friend, a loved one, or a family member and wondering about one of the following questions:

1.  How do I identify depression? 
2.  How do I understand this particular depression? 
3.  How do I approach doing the right thing(s) about this depression?  

I have organized the information below along the lines of these three basic questions.

How Do I Identify Depression?

Depressive feelings are a common part of life.  They come and go.  They are not always a sign of illness and actually can be an important source of guidance as we navigate the complex waters of a human life. The first question to answer, therefore, is whether to view your current depression as normal or pathological (an illness). 

Normal depression will have fewer of the symptoms (a medical term that designates aspects of a condition) listed below. Pathological depression will have more and is a source of great suffering both to the person who has it, and to those closely associated with them.  Here is a list of the symptoms we usually associate with depression:         

•    Persistent sad, anxious or "empty" feelings
•    Feelings of hopelessness and/or pessimism
•    Feelings of guilt, worthlessness and/or helplessness
•    Irritability, restlessness
•    Loss of interest in activities or hobbies once pleasurable, including sex
•    Fatigue and decreased energy
•    Difficulty concentrating, remembering details, and making decisions
•    Insomnia, early morning wakefulness, or excessive sleeping
•    Overeating or appetite loss
•    Thoughts of suicide, suicide attempts
•    Persistent aches or pains, headaches, cramps or digestive problems that do not ease even with treatment

A handy mnemonic (remembering device) for these symptoms that psychiatrists and psychologists commonly use is:
       
SIGECAPS=SIG + Energy + CAPSules
Sleep disorder (either increased or decreased sleep)*
Interest deficit (anhedonia)
Guilt (worthlessness,* hopelessness,* regret)
Energy deficit*
Concentration deficit*
Appetite disorder (either decreased or increased)*
Psychomotor retardation or agitation
Suicidality

To meet the diagnosis of major depression, a patient must have four of the symptoms that have asterisks, plus depressed mood or anhedonia (inability to feel pleasure), for at least two weeks. To meet the diagnosis of dysthymic disorder (persistent mild depression), a patient must have two of the six symptoms marked with an asterisk – plus depression – for at least two years.)

    These symptoms are elements that we can see in others and/or in ourselves.  Currently, in clinical psychiatry, we start by identifying the current symptoms, and then we look at the impact of the depression on the person’s work life and their relationships.  In the identifying (or diagnosing) phase, we look at the depth of the depression (number of symptoms, severity of impairment) and the time course. The following outline may provide a useful guideline for placing your depression on the spectrum of how a psychiatrist or psychoanalyst might think of it.

1.    Patient describes a short time course (less than 2 weeks) and few symptoms (not suicidal)
a.    Possible causes
1.    Acute loss, part of a normal emotional reaction, acute grieving
2.    Self-esteem injury, betrayal, sudden change of fortune at work
3.    Reaction to a chemical (drug-induced, including chemotherapy)
b.    Likely Treatment
1.    Short-term support (perhaps a session or two of individual or family-based counseling) during which we understand cause, minimize the impact on work or relationships (perhaps a medicine for sleep), and maximize the opportunity for learning.

2.    Patient describes a longer term course (months, years) and few symptoms (not suicidal)
a.    Typical Symptoms
1.    Tend to include SIG (sleep, interest, guilt) and a chronic sense of feeling unfulfilled and dissatisfied.
2.    Impact on relationships may be to wear them down, or not fully connect; impact on work may be underperformance, not realizing potential.
b.    Likely Treatments
1.    These kinds of depression can show modest improvement from modern antidepressant medicines (such as the selective serotonin reuptake inhibitors [SSRIs] like fluoxetine [Prozac] and citalopram [Celexa]). In many parts of the country that may seem to be all that is available.
2.    These long-standing mild forms of depression are also the types that respond lastingly to high-quality psychological therapies, like psychoanalysis or psychoanalytic psychotherapy where a significant relationship with a skilled therapist provides an opportunity for major emotional growth that can “turn a life around.”  It can be a waste of the human potential for these developmental opportunities to be too quickly submerged in a medication-based “quick fix” approach that assuages the pain with medicine.


3.    Patient describes a longer term course (more than four weeks) and many symptoms (including suicidal)
a.    Typical Symptoms:
1.    As this type of severe depression (called Major Depression) progresses, there is significant impairment at work (loss of concentration, poor performance, even not showing up for work, low energy) and in relationships (withdrawal, unpredictable, bitter).
2.    There can be examples of distorted or delusional thinking such as persecutory thoughts, or somatic (physical) distortions where the person might think to him or herself: “I am rotting inside.”  Delusions can also intertwine with suicidal (aggression turned on the self) urges and people can think “the world would be better off without me,” and seem to completely lose sight of their importance to loved ones.
b.    Likely Treatments:
1.    Even if a person can weather this severe form of depression and begin to recover within months, usually the fall-out from this kind of severe illness is lasting (emotional scar tissue). This provides an ongoing reminder that more active treatment is a much better way to go during the acute phase of illness, because it can minimize enduring forms of damage to family life, work reputations, and self-regard.  We will discuss the details of treatment below, but suffice to say here that there are a wide range of potential treatment options, all of which may be necessary to effectively treat this potentially lethal form of depressive illness. (Effective treatment usually involves comprehensive attention to family, environment, and patient welfare, as well as medication and, possibly, hospitalization and electroshock therapy.)  None of these options eliminate the usefulness of long-term therapeutic and medication-monitoring relationships, which then take on the tasks of fostering developmental growth, self-understanding, and relapse prevention.


4.    Patient describes a longer term course but with waxing and waning (symptoms may be many or few)
a.    Typical Symptoms
1.    Depression, both in its mild and severe forms, may appear in the context of a cyclic form of mood disorder that we often think of as Manic-Depressive or Affective disorder spectrum.  These cycling forms of depression aren’t always interspersed with full-blown manias (crazy, grandiose, impulsive, destructive periods) but may, instead, be separated by periods of normal function or periods of seeming super-functioning (getting a tremendous amount done, needing little sleep, optimistic mood).
b.    Likely Treatments
1.    When depression occurs in a context of cycling, the approach to understanding the depression and treating it can bear important differences.  For example, the use of straight antidepressants can, in this group, cause the onset of a manic episode or simply make the emotional life even more prone to sudden ups and downs. 
2.    If medication becomes a necessary part of helping a person with this cycling form of depression, the first-line medicine should be a mood stabilizer.  People often think of lithium in this context, but there are also other effective mood stabilizers such as lamotrigine (Lamictal).  With these mood stabilizers in place, then an antidepressant, if it becomes necessary, can be used gingerly without precipitating a manic episode, or more rapid cycling.
3.    Often, a person with cycling depressions will have not learned to trust in their primary relationships, and therapy will often become a learning environment where the conflicts between trust and suspiciousness can be resolved in an enduring human connection.

How Do I Understand this Particular Depression?

To understand any particular depression you may be faced with, it is important to consider some basic background on the illness.  First, from Freud through data gathered in child and infant study centers as well as from MRI scans and an understanding of brain development (Dan Stern, Peter Fonagy, Dan Siegel just to mention a few) it is becoming more clear that the capacity to experience sadness is a vital human achievement and an important piece of normal human experience.
In its normal form, depression is a part of how we make attachments between infants and caregivers that remain stable parts of our selves even as we grow toward more independence and autonomy. A loving, reliable form of caregiving seems to foster this secure attachment, and this capacity to weather sadness. Without the benefit of modern brain imaging, Sigmund Freud and, later, Melanie Klein noticed the shifts in affect (emotional qualities of experience) from the sadness a baby shows at separation to the gladness apparent when the mother reappears. It is in this capacity for tolerating sadness that the young child begins to create a mental image of the caregiver that keeps them company when the mother is away. Sadness is an internal feeling state accompanied by tears and physical feelings that can become linked with memories of the caregiver in ways that provide a kind of solace to the developing child.  There are many feeling states in the developing child, but to place the developmental importance of depression, we should compare it to anxiety, which is a signal of some danger, or even unpleasantness (like hunger, cold).  If a child does not have sufficient loving or caregiving then they may come to experience more purely anxious states when they are alone, during periods of separation. They focus more on the evidence of maternal presence, so only calm down when they have the mother present, for example. In this case, only seeing is believing – not feeling. 

If you’ll permit me a sailing metaphor: if as children – or adults with good treatment – we can develop the capacity to experience depression as sadness or mourning and can allow the internalization of important people and connections to occur during the sadness or mourning, then we sail life’s waters with an internal guidance system; we can feel when we are moving toward or away from people, values, and goals that are vital to us. The course of our lives becomes something we can remember through this inner connection. On the other hand, if the capacity for depression does not develop then we are thrown more on the uses of anxiety in all its forms. The child may use fantasy and the denial of feeling states to survive separations. Dangers are seen everywhere. The felt sense of inhabiting a physical body is inhibited.  The child’s mental life becomes more filled with visual and objective imagery, with security coming from the sense of being able to manipulate and control these thoughts and objects. He or she is only assured by physical evidence, such as seeing the mother return; when the mother is gone, the child cannot feel and be reassured by the emotional connection to the mother from which other children attain reassurance.

Whether or not the preceding paragraphs’ attempt to condense vast amounts of research and experience makes sense to you, the most important idea to take away from it is that when you or a loved one is depressed, it is very important to ask: “Is there some opportunity for growth lying within this episode of depression?” This opportunity to change our personal bias from anxiety and fear to one of manageable depression and inner security does not disappear because we are no longer children.  On the contrary, it seems to be a human urge that is with us throughout life.  If we only view depression as an emotional flu or pneumonia, we will waste these opportunities for growth.
Now that I have described why we should not automatically regard depression as an illness, I can list some important kinds of depression to give you some food for thought concerning the particular depression you are trying to understand:
1.    Trauma – Depression can occur following or during trauma.  The depression that we have long seen in war veterans can be a serious and powerful symptom of having lived through severe trauma.  Fearing for one’s life, taking life, feeling the lack of civilian understanding for one’s experience can all lead to a depression that often signals that personal resources have been overwhelmed.  The ability to think about experience and to describe it may have been so damaged that numb, mute states occur.  Treatment for this condition often begins with medication (like the SSRIs) that can soothe and mute the intensity of neuro-psychic reactions to remembering; these reactions are often called triggering.  The amygdala (a part of the brain below thought that gets over-activated in continued trauma) may be so ready to fire that a brief effort at conversation results in an eruption of war-zone anxiety and rage. This might happen during family gatherings with war-ravaged returning vets, resulting in great scarring for families, but more so for the returning vets. A period of cooling the nervous system – medication, meditation, the passage of time – is vital before embarking on too much remembering and recounting.  These same principles apply to all forms of trauma, including becoming a refugee, torture, and sexual and domestic violence. The traumatized nervous system needs care and soothing before psychological talking is embarked upon.
2.    Substance Abuse – Depression may occur during extended periods of alcohol or substance abuse. It also may occur during the many early months following some rehabilitation treatment, during the “drying out” phase. It is a characteristic appearance of someone whose nervous system, particular their brain in all its complex layers, is slowly recovering from extended exposure to toxicity. Supportive relational systems such as Alcoholics Anonymous (AA) provide much needed structure during this phase, whereas antidepressants are of marginal value (not to say that some people have not benefited from antidepressants during this phase).  Once the first year of drying out has been accomplished, if there are significant lingering symptoms of depression, they can and should be approached with appropriate psychological and pharmacological treatments.
3.    Post-Partum – By the time she finally gives birth to her baby, a woman’s body has been through a hormonal roller coaster.  For some women this results in a profound depression, often one that began during pregnancy.  Much research (Lee Cohen, et al at Massachusetts General Hospital) has established that this gestational depression, during or after pregnancy and birth, can and should be treated with medication (Sertraline hydrochloride [Zoloft] has the longest track record for safety, but others are getting approved as safe) as well as supportive psychotherapy. Active and effective treatment helps not only the mother, but the infant whose attachment experience depends on having an emotionally available maternal caregiver.
4.    Seasonal Factors – There is extensive research on the effect that light has on our bodies and emotions.  For those who are prone to severe experiences of depressed mood in the fall months, various light boxes have been developed and data shows their benefit (Janis Anderson at Brigham and Women’s Hospital).
5.    Sudden Loss/Betrayal – Both in the world of our relationships and our work, sudden, unexpected loss can occur (a sudden firing; a company being taken over; a sudden affair; the death of spouse, parent, loved one, or child).  These sudden losses precipitate major emotional crises that often result in acute depression.  People weather these sudden losses in all kinds of ways, including personal support, withdrawal, and spiritual communities.  In addition to providing help and support, a therapist can help the person who is suffering acutely in all kinds of ways. These may include deciding about the type of treatment and providing a private, confidential setting to come to terms with the loss.  We will discuss this further in the next section on how to approach an episode of depression.
6.    Stress – The unremitting stress of life may certainly begin to culminate in depression. It can also lead to periods of unresolved anxiety as well.  Some qualities of stress-related depression are: a) it can be hardest to recognize in the person themselves, so they need another to tell them they have become “not themselves,” b) it has a lot of physical accompaniments, like insomnia, poor health, poor habits, short temper, and poor attention; we have an epidemic of people who feel they have developed “attention deficit disorder,” which is really stress. Good and effective approaches are available for stress-related depression that range from Mindfulness Based Stress Reduction (see website for Center for Mindfulness at University of Massachusetts, Worcester (http://www.umassmed.edu/cfm/index.aspx) to individual and group psychotherapy and psychopharmacology (medication).  Probably the most important thing is to recognize that stress-related depression has occurred and that some “course correction” needs to happen.  People can successfully seek and manage great amounts of stress. But again, depression, as that all important emotional signal system that we as human beings possess, needs to be noticed and heeded as a signal to change our way of approaching the stress – to grow, as it were.
7.  Major Depression – This is the illness. William Styron’s book (Darkness Visible: A Memoir of Madness) is an elegant description of this kind of depression.  It is the kind that may recur in life, that may have been seen in other primary family members (parents, siblings) and that doesn’t seem to necessarily require an event to start it, such as a trauma or loss.  It can appear to a loved one that the person has been colonized by some dark, foreign army that has almost consumed the person they once knew and loved.   Suicide is a risk, whether the depressed person acknowledges it or not.  Treatment should not be approached tentatively.  Emergency rooms should be staffed by people with psychiatric training. One of their main responsibilities is to prevent suicide – that permanent solution to a temporary problem.  The pain and intolerable darkness that a severely depressed person feels can dramatically undermine their capacity for rational thinking.  In a sense, loved ones can no longer really trust what the severely depressed person is saying.  Depressed college students who tell their college-based counselors that they do not want their families notified (Wall Street Journal, January 2007 “Bucking Privacy Concerns, Cornell Acts as Watchdog Staff Trained to Spot Students in Distress; Campus Suicides Drop,” By ELIZABETH BERNSTEIN December 28, 2007; Page A1) and then go on to kill themselves provide an example of the responsibilities of treatment personnel to assess irrational suicidal intent, to breach confidentiality, and to temporarily use involuntary mental hospital commitments to save lives. Anger, frustration, hatred and murderousness have built up in the person with major depression and suicidality.  For those of us who have had the misfortune to be around after a suicide, the feeling that predominates is that someone has been murdered, not released. It is only that the murderer was the person themselves. 

How do I approach doing the right thing(s) about this depression?

Once you have done the work of identifying the depression and attempting to understand it, how you approach doing the right thing(s) about it is a highly personal decision.  In general, even in my own clinical practice, I do not feel that I immediately know the right approach for a particular patient seeking my help with their depression. I have taken to describing myself as a psychiatric/psychoanalytic Sherpa (guide) to my patients.  By that I mean that I have been toiling in these mountains for years and have some sense of what it takes to get to one peak or another, but I am here to serve the patient. I need to help them tell me how they would like to go and, more importantly, where they would like to go. They – and you – have to pick the mountain, as it were, and then I can help with the getting there. Reading this, however, you are not in my office, so below I offer these general thoughts that I hope will be helpful.
First, talk with someone you trust.  Tell someone, if they don’t already know, that you are feeling depressed and are wondering what to do about it.  Just the simple act of telling someone helps to begin the approach to doing the right thing.  It makes it more real. You can hear not only how it sounds to tell someone, but how it sounds to you to hear yourself say it. 
Second, approach the mental healthcare system through a trusted relationship if you can.  This can be a primary care physician, a child’s pediatrician, a minister, family member, friend of a family member, friend of a friend. This relational approach to connecting with a mental health provider tends to work better than the “yellow pages” approach.  I do understand that this network may not be available to everyone.  If it is not available to you, then I would recommend consulting one of three excellent websites:  1) The American Psychiatric Association (http://www.psych.org/); 2) The American Psychoanalytic Association (http://www.apsa.org), and; 3) The American Psychological Association (http://www.apa.org/).  All three of these have “find a provider” sections that can lead you to well-trained people in your area.  A fourth website, the National Institute of Mental Health (http://www.nimh.nih.gov/), contains a wealth of information with links to research, treatment, and public information.
Third, at your first visit with your initial provider, take a trusted loved one or friend with you.  Most good quality mental health clinicians welcome the presence of a loved one at the first visit. The loved one may not stay the entire visit, but this first visit needs to provide the opportunity for the doctor, psychologist, or social worker to gather as broad a spectrum of information as possible. Ask questions, take notes, and ask yourself if you’re feeling comfortable with this person’s approach.  No one with good sense and good training assumes that they are the right person for all the people who come through their office door. You should even try to imagine saying: “I feel you are very competent, but I do not feel that we would be a good match.  Knowing what you know of my situation, could you suggest a colleague who might be a better fit for me?”
Lastly, I recommend that you and your loved one keep this following simple diagram in mind as you approach doing the right thing for your depression. I often draw it in the shape of a pyramid that has three horizontal layers (Figure One).  You could think of it as a mountain, and recall my habit of describing myself as a Sherpa. I am going to describe the layers from the bottom up, which is the order that you (and, I would suggest, the person or persons you choose to help you) should think of them.
1.    Base Camp – This is the layer of your symptoms: your nervous system, your body, your pain, distress, capacity to think clearly, and capacity to connect to and tolerate your emotions.  Particularly in severe depression, before moving on this area needs the time and attention necessary for improvement and stabilization. If the ability to safely navigate in the world is impaired, a hospitalization, even a brief one, should be considered. If a dark mood is clouding your ability to think, medication should be started immediately.  If, in the first meeting with a provider, talking and emotional release occur such that symptoms lighten, then medication and other somatic therapies can be held in abeyance. A second session and a third can occur to see if this improvement at the base level continues or needs to be supplemented.  Attention should be paid to all the physical realms: appetite, sleep, exercise, body centering, and calming techniques.  Some consideration of these body level issues is primary. In the case of trauma, a loved one may need to provide the history, so that the suffering person does not have to re-traumatize and retrigger him or her self in giving the history.  In such cases, medication should be discussed immediately. Visits, close observation, and communication plans should all be in place at base camp before moving on.
2.    The Trek – This may describe the journey of psychoanalysis, psychotherapy, or a course of treatment in which the initial clinician (Sherpa) is employed as a coach, guide, and triage person.  It depends on you and your depression how much this trek is an inner journey, and how much it is an external journey.  Either way, it is likely that journey will include learning and change both inside and outside.  As the trek begins, important attention should be given to the basic areas of relationships and work. What Freud said years ago is still fundamentally true:  good treatment can help people in the areas of love and work. If the depression began as a major illness, the first issues above base camp may be a gradual return to work or perhaps, a scaled back approach to work. Group treatment, and frequent supportive sessions may be necessary to support a steady re-integration into work, school, or family responsibilities.  Relationships – in the form of family, spouses, children – all need to be considered and supported.  One problem that I’d like to see you avoid is when the treatment relationship becomes so central that the rest of the people in your life don’t get included the way they should in both the recovery phase and the healthy phase that, hopefully, follows. Observed experience becomes the great source of discussion in treatment during this phase, which can go on for years, depending on all kinds of factors. 
3.    The Mountain Top – Here is where we get to look back on the journey and consolidate what has been learned.  Many people in my field subscribe to the notion that “insight is 90 percent hindsight.” This means simply that we learn from experience. We look back on experience, as well as looking at it as it happens.  In years gone by too many traumatic psychiatric encounters occurred where analysts and therapists tried to provide insight at the beginning, forgetting that base camp needed to be established and the trek needed to be experienced.  Of course, insight and understanding are gathered along the way, but it turns out to be very useful to put the overview, the durable insight, at the top, at the place of arrival.

I will append other useful resources here as well as a bibliography.

Figure One.