Understanding Depression
Understanding depression is an important element in the treatment of clinical depression. The Diagnostic and Statistical Manual (DSM-5), the primary resource for psychologists and psychiatrists, makes clear that Depression is not just sadness.
Depression is a clinically significant condition, with biological causes and effects, that can dramatically decrease quality of life, and have significant consequences on anyone suffering from it.
Types of Depression
There are many types of depression, all of which have been researched and defined by psychologists, and described in the DSM-5.
1. Major Depression (or Major Depressive Disorder) is a condition in which you deal with intrusive and distressing symptoms more days than not, for most of the hours in those days. Symptoms include feeling down; no longer taking pleasure in most activities (anhedonia); disturbances in sleep, appetite, and activity level; difficulty concentrating, and thoughts of suicide. Not all symptoms have to be present to meet criteria for Major Depression, and there are different levels of severity. Mild Depression is the least severe, Moderate Depression is more significant, and Severe Depression involves the most acute symptoms, often including suicidal ideation.
2. Persistent Depressive Disorder (formerly Dysthymia) is a more mild, but chronic form of depression. It involves many of the same symptoms as those associated with Major Depression, but they are not as acute, and they are longer in duration. If you suffer from Dysthymia, you may feel “not great” most of the time, for long periods of time, whereas those with Major Depression are more likely to have “episodes” of more acute symptoms.
3. Postpartum Depression is an episode (or episodes) of depression that occur within a year of giving birth. Postpartum Depression can be mild, moderate or severe, just like Major Depression, and can be particularly challenging in the midst of dealing with a newborn, and the cultural/social expectation that new parents “should be happy.” In rare cases, Postpartum Depression can include psychotic symptoms that can endanger the mother and/or the baby.
4. Seasonal Affective Disorder (SAD) is a version of depression that generally occurs in certain seasons, usually winter, often brought on by the absence of the sun (i.e. longer, darker days) and the presence of cold temperatures (generally precluding outdoor activity). SAD is more common in northern regions, where winters are longer, darker and colder.
5. Bipolar Disorder includes episodes of depression and mania. Bipolar 1 has depressive episodes that meet criteria for Major Depression, and episodes of mania that can be threatening to your or others’ safety (e.g. risky or extreme behavior, not sleeping, etc.). Bipolar 2 is a more mild version of Bipolar Disorder, in which depressive episodes are more similar to Dysthymia, and manic episodes are more likely to involve hyper-productivity or high levels of energy.
Depression: Symptoms and Diagnosis
The symptoms and diagnostic criteria of depressive disorders overlap with each other, and are outlined below:
1. The symptoms of Major Depressive Disorder (MDD) are depressed mood, most of the day, nearly every day, which can be observed by self or others; diminished interest in almost all pleasurable activities (known as anhedonia); changes in weight; disturbance in sleep (or sleeping too much); psychomotor agitation (i.e. fidgetiness) or slow-down almost every day; fatigue or low energy; feelings of worthlessness or inappropriate guilt; difficulty thinking or concentrating; and recurrent thoughts of death, or even suicidal thoughts. To meet criteria for MDD, at least five of these symptoms need to be present during a two-week period, and one of the symptoms needs to be either feeling depressed or experiencing anhedonia (Diagnostic and Statistical Manual of Mental Disorders, 5th Edition).
2. The symptoms of Persistent Depressive Disorder (Dysthymia or PDD) are depressed mood most of the time for at least two years; and at least two of the following: poor appetite or overeating, insomnia or hypersomnia, low energy or fatigue, low self-esteem, poor concentration or indecisiveness; and feelings of hopelessness (ibid.). You may recognize the similarities between symptoms of PDD and MDD; the primary difference is in the acuity and duration of the symptoms. People experiencing PDD may or may not have less severe symptoms, but they last much longer.
3. The symptoms of Postpartum Depression, as defined by the Mayo Clinic, can include depressed mood or mood swings, withdrawal from your baby, fear that you’re not a good mother, feelings of hopelessness or worthlessness, disturbances in sleep (not related to your baby), disturbances in appetite, fatigue or low energy, irritability/anger, difficulty concentrating, and anhedonia (loss of pleasure in enjoyable activities). Diagnosing Postpartum Depression can be difficult because many of the symptoms include feelings or phenomena that occur naturally with the birth of a baby. It can be very helpful to take other people’s feedback about how you’re doing, in order to catch signs that you may be suffering from Postpartum Depression.
4. The symptoms of Seasonal Affective Disorder (SAD) include all the symptoms of MDD and Dysthymia (please see above). However, SAD occurs seasonally, most often in the winter, and generally remits on its own when warmer or brighter weather returns. Even so, many people suffering from SAD benefit greatly from receiving treatment on a seasonal basis to respond to their symptoms.
5. The symptoms of Bipolar Disorder include symptoms of manic episodes and symptoms of depressive episodes. Symptoms of depression are listed above, under Major Depressive Disorder and Persistent Depressive Disorder. A manic episode is highlighted by, according to the DSM-5, “a distinct period of abnormally and persistently elevated, expansive or irritable mood and abnormally and persistently increased goal-directed activity or energy, last at least one week and present most of the day, nearly every day.” Additionally, the following symptoms (at least three of them) must be present: inflated self-esteem, decreased need for sleep, talkativeness, racing thoughts or flight of ideas, distractibility, increase in activity, and excessive involvement in high-risk activities (e.g. buying sprees, unsafe sexual practices, ill-advised financial decisions). In order to meet criteria for Bipolar 1, you must meet criteria for both an episode of Major Depressive Disorder and a full manic episode. To meet criteria for Bipolar 2, you must meet criteria for either MDD or PDD (Dysthymia), and have a hypomanic episode (defined by the same symptoms as a manic episode, but can be as short as four days in duration, and have less serious impact on your life).
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Mental Health Professionals and their Roles in treating depression
Mental health professionals play a critical role in the treatment of all forms of depression. A recent study at Stanford found that one treatment of depression had a 79% success rate for individuals with severe depression. Studies of traditional therapy show more modest results, but a therapist is an essential element in depression treatment. A mental health professional (whether a psychologist, therapist or psychiatrist) provides a source of support and resources, tools and suggestions for responding to depressive symptoms, and sometimes simply structure in a life that can begin to feel it’s veering off-course.
The role of a mental health professional is to assess your symptoms; take a holistic look at you, your history, and your current circumstances; provide tools for feeling better; and help create a plan to get your depressive symptoms under control.
Depression Treatment: Finding the Right Professional
Finding the right professional to treat your depression can feel daunting, but it does not need to be. The most important elements to look for when finding a therapist include valid licensure or supervision by somebody with a valid license (an absolute must), some demonstration of competence (i.e. look at their education and experience), and a sense that you can feel comfortable with them. Many therapists will provide a free introductory phone call so you can ask some questions and get some sense of who they are, and whether they will be a good fit for you personally. Sometimes you won’t be able to get this clarified until you sit with them for a session or two. If you are somebody who needs a lot of accountability, perhaps you look for a more direct therapist. On the other hand, if you prefer having a lot of space to make your own decisions, you may be looking for a therapist who asks really great questions that help you clarify your own thought processes. It may help to watch this video to get some ideas on how to effectively go through this process.
Medication Options for Treating Depression
There are more and more medication options for treating depression, as evidenced by commercials and ads on TV and the internet. It can be tricky to know which medication options are right for you. As a psychologist, I do not have medical training, and therefore can only give a high-level overview of the types of medication. If you are seeking medication treatment for depression, you will want to schedule an appointment with your general practitioner or a mental health prescriber (i.e. psychiatrist, clinical nurse practitioner, etc.).
1. Selective Serotonin Reuptake Inhibitors (SSRIs) are the most commonly prescribed medication for depression. These include Prozac (fluoxetine), Zoloft (sertraline), Celexa (citalopram) and other names that you may recognize. They work by allowing more serotonin (a “feel-good” chemical) to be present in your brain.
2. Serotonin and Norepinephrine Reuptake Inhibitors (SNRIs) are very similar to SSRIs, but have been developed more recently. They include, most famously, Cymbalta (duloxetine) and Effexor (venlafaxine). These drugs operate by allowing both serotonin AND norepinephrine (another “feel-good” chemical) to operate more freely.
3. Atypical antidepressants, such as trazodone and Wellbutrin (buproprion), among others, operate
4. Tricyclic antidepressants are an older category of antidepressants, and include imipramine and amitriptyline (among others). While they can be quite effective, tricyclics tend to be associated with higher side effects than SSRIs or SNRIs, and are therefore rarely prescribed unless other prescriptions have proven ineffective.
5. Monoamine Oxidase Inhibitors (MAOIs) are another older category of psychiatric medication. The primary reason they are not often prescribed is because they can have significant, even lethal, interactions with certain foods and other medications. For example, MAOIs can never be taken in combination with SSRIs or SNRIs. One newer MAOI (Selegiline or Emsam) can be applied as a patch, and seems to have fewer side effects than ingested medications. However, just like tricyclics, MAOIs are rarely prescribed until and unless other medications have failed.
Risks and Side Effects of Depression
The risks and side effects of medications vary dramatically, and each individual should talk to their prescriber about their personal risks before beginning a medication. As detailed above, the older categories of antidepressants have more, and more severe, side effects, but some people taking SSRIs and SNRIs complain of a range of (usually more mild) side effects. These include, but are not limited to, weight gain, sexual side effects, dry mouth, or nausea. Additionally, if you are pregnant or breastfeeding, you will want to consult your doctor before starting any antidepressant. Finally, although rare, starting an antidepressant can sometimes coincide with suicidal ideation or attempted suicide. It is possible that an initial increase in energy can occur before an improvement in mood, and lead to suicide. Again, no matter your situation, it is critical to begin an antidepressant under the advisement of a medical professional, who can help monitor effectiveness and/or possible side effects, and make changes as needed.
Psychotherapy Approaches in treating Depression
There are multiple psychotherapy approaches to treating depression. Cognitive behavioral therapy (CBT), dialectical behavioral therapy (DBT), acceptance and commitment therapy (ACT), solution-focused therapy, and psychodynamic therapy are some of the main approaches.
1. Cognitive behavioral therapy (CBT), developed by Glenn Beck, PhD, in the 1960s and commonly referred to as the most effective treatment for depression, is a skills-based treatment wherein your therapist helps you identify unhelpful, and likely untrue, thoughts and beliefs. Once they are recognized, you will learn a variety of strategies to begin challenging the thoughts, such as cognitive restructuring, gathering evidence to the contrary, etc.
2. Dialectical Behavioral Therapy (DBT) was developed by Marsha Linehan, PhD, and also relies heavily on skill-building to help treat your depression. Whereas CBT targets your thoughts and beliefs with cognitive strategies, DBT utilizes specific behaviors that can help your brain process thoughts differently. DBT can be done individually or in a group, or both, and is effective for a number of other diagnoses in addition to depression.
3. Acceptance and Commitment Therapy (ACT) became popular in the early 2000s, and focuses on accepting thoughts and beliefs as outside your control. Instead of trying to specifically change them, your ACT therapist will help you tolerate those thoughts and feelings while engaging in behaviors that are in line with your values (and generally inconsistent with the unhelpful thoughts and beliefs). In my practice, I primarily use this approach, and find that it gives my clients a higher sense of agency in that they can choose behaviors that line up with the kind of person they want to be.
4. Solution-Focused Therapy is a short-term therapy designed to help you learn the skills to most quickly and effectively solve problems to reduce your depression symptoms. You and your therapist work together to identify the problems or issues contributing to your depression, and then develop different strategies to mitigate those problems. Since the issues that are negatively impacting your mood improve, you’ll generally find that your mood improves as well.
5. Psychodynamic Therapy encompasses several different types of therapy under one umbrella. What these different techniques have in common is that they work to uncover unconscious beliefs and ideas, many of which have been in place since childhood, that are contributing to your negative feelings and mood. Once you can understand how these ideas got planted, you can work on understanding them better and begin to dismantle them, generally through frequent and regular talk therapy.
Individual vs. Group Therapy for depression
Individual therapy is one-on-one therapy with your therapist, who you have carefully chosen because you are comfortable with them, and they have demonstrated competence in the issues from which you struggle. Most individual therapy begins with weekly sessions, and the very first sessions are spent identifying the reasons for beginning therapy, taking a history of your symptoms, and developing a treatment plan for ongoing therapy. As you begin to feel better, you may start to meet less frequently, perhaps decreasing to every other week, every three weeks, or monthly. At some point, after discussion with your therapist, you will decide that you have learned enough skills and/or gathered enough insight to respond to your symptoms independently. At that point, your therapist will guide you through a termination session, in which you review what you’ve learned and the skills you’ve established, and complete therapy. In my own practice, and that of most therapists, the door is always open to return to therapy if and when you feel it could be helpful. Some people find that “maintenance therapy” can be helpful, at which point you meet every several months to “check in” and potentially catch any issues that have the potential to become problematic.
Group therapy is therapy with one therapist (sometimes two) and several other people who are dealing with (usually) similar issues to yours. Some group therapy is designed to be merely supportive (i.e. a support group), where you listen to each other and provide sympathy and empathy. Other groups are more process-oriented, where the trained group therapist works to help uncover patterns that emerge within the group, generally mirroring issues that likely occur in real life. As these patterns are pointed out, group members work through the issues that are causing them, providing invaluable practice for working through issues with friends and family. Other types of groups can also be helpful, including dialectical behavioral therapy (DBT), specifically designed for skill-building, chemical dependency groups for supporting abstinence or harm-reduction, or others. Group therapy can be quite helpful on its own, or in tandem with individual therapy. In ideal circumstances, your individual and group therapist communicate with each other to help maximize results for their clients.
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Lifestyle Changes for Depression Management
Multiple strategies exist for managing depression simply by adjusting your lifestyle. Although simple, these changes are rarely easy. There are a variety of changes that can be made that will often help mitigate symptoms of depression.
- Healthy eating is a powerful way to decrease depression symptoms. Our brains and bodies are inextricably linked, and when one or the other suffers, the other is bound to struggle as well. The better you eat (a balanced diet of lean proteins, tons of fruits and veggies, healthy grains, and minimal healthy fats and sugars), the better your body feels. The better your body feels, the more likely your brain is to respond healthily to stressors. In fact, the National Institute of Health (NIH) has noted that “the most well-established example of mind-body interaction is the link between psychological stress and psychological ill-health.” Simply put, if you feel physically terrible, you are far more likely to struggle with negative emotions.
- Exercise also helps promote positive mental health and reduce mental illness. While the most profound mitigating effect of exercise was found for anxiety, there is a significant positive impact of exercise on symptoms of depression as well. The Mayo Clinic indicates that “working out and other forms of physical activity can ease symptoms of depression and anxiety and make you feel better.” Something as simple as walking for 5-10 minutes a day can make a substantial difference in your psychological wellbeing.
- Getting outside on a regular basis is also a great way to decrease your symptoms of depression. Studies are quite clear in establishing an inverse correlation between exposure to sunlight (even behind cloud cover) and depression. In a meta-analysis of many studies examining this issue, the NIH found that “sunlight provided protection against a wide range of diseases–not only physical disease but mental disorders.” It can be challenging to force yourself outside when you’re depressed, but it is clear that the effort will very likely pay off, either in the short term, the long term, or both.
Implementing Healthy Habits
The lifestyle changes described above can be challenging to implement, despite your best intentions. There are multiple ways to go about developing new habits, many of which can be discussed and/or practiced and implemented with a competent mental health professional. I’ll provide a few ideas here, but I highly recommend seeking out therapy and/or written resources (I particularly like “The Happiness Project” by Gretchen Rubin, as well as her podcast) so you don’t have to go it alone.
- Linking: By linking an activity that you really enjoy (e.g. watching your favorite TV show or listening to music) with an activity that is hard to make yourself do (e.g. going for a walk, folding laundry), you can begin to establish a positive association in your brain with the previously undesirable activity.
- Accountability: Many people find that challenging activities are easier to face when they have told somebody they are planning to do it. Or if they plan to do the activity WITH somebody in their lives. Going for a walk is another great example. Suddenly exercise (groan) becomes time with friends (yay!).
- Working downhill: Most of us save the “worst” task on our to-do list for last. Right? Unfortunately, this only contributes to the dread and anxiety associated with the task. Try flipping the list by doing the most dreaded activity first, when you have the most energy. Suddenly, surprise! You’ve actually created energy for yourself by getting that knocked out, and you are more prepared to tackle the rest of what you’ve lined up for yourself.
FAQs on Anxiety
- Response: Response is the first step in healing from Depression. It involves the first decrease in symptoms, or the first moment in which you “feel better.” Response is the first step toward a higher, more long-lasting level of improvement.
- Remission: Remission is the state of being free of depressive symptoms. You have moved from having moments where you feel better to having days in a row where you do not feel depressed. You may describe a sense of wellbeing that feels entirely different from Depression.
- Recovery: Recovery is the period of time where you’ve been in remission for at least four months, and you can observe both good days and bad days. You are certainly feeling better than when you were depressed, and you may be implementing new skills and strategies to maintain this level of wellbeing. This is no walk in the park; it’s real life, with real ups and downs.
- Relapse: Relapse is a return of a full slate of depressive symptoms prior to reaching four months of remission. Take heart: you have already gotten there once, and you can get there again. Keep applying the strategies that helped you achieve Remission the first time.
- Recurrence: Recurrence is the appearance of another depressive episode after you’ve attained full Recovery. Again, this is disheartening, but not disastrous. After reaching Recovery at least once, you can return to the skills and strategies that have worked in the past.
- Persistent low, depressed mood
- Loss of pleasure in previously enjoyable activities
- Low energy or fatigue
The drug of choice for depression is more accurately a category of choice, and that is SSRIs (Selective Serotonin Reuptake Inhibitors). This category includes Prozac (fluoxetine), Zoloft (sertraline), Celexa (citalopram) and other names you’ve heard on commercials, social media, or from friends. These drugs allow serotonin (a feel-good chemical) to stay in the brain longer, promoting a higher sense of well-being.
- Acute: Acute treatment is the early part of therapy, where are you working to establish relief from the daily symptoms of depression. It’s hard work, but you get glimmers of hope when you achieve moments or days of remission.
- Continuation: Continuation is the stage of treatment wherein you are working to establish habits that prevent a relapse into symptoms of depression. You and your therapist have found skills and strategies that work for you, and your job is to turn to build these into your daily life.
- Maintenance: Maintenance is the stage of treatment where you are working to prevent recurrence of depression. Your effective habits are well-established, and you know how to respond to triggers or stressors that are likely to bring on symptoms of depression.
Alternative and Complementary Treatments in depression
There are a host of alternative and complementary treatments available for depression, which can be used in addition to, or instead of, the more traditional psychotherapy approaches described above.
- Acupuncture is a traditional Chinese medicine wherein trained practitioners use their knowledge of the body and qi (a naturally occurring energy within the body) to precisely insert tiny needles into the very top surface of the skin. The result is often a mitigation of a targeted symptom, whether psychological or physical.
- Biofeedback is a treatment taught by trained professionals, wherein you learn to monitor your own vital systems (i.e. heart rate, breathing) to calm those systems, also easing the symptoms of anxiety and/or depression that accompany their rise.
- Herbal Remedies are another type of traditional Chinese medicine wherein practitioners administer carefully dosed ground dried herbs for ingestion. The goal is, again, to decrease psychological or physical discomfort.
- Massage/Reflexology are both forms of body work that can provide physical relief of tense muscles, which can also aid in promoting relaxation and a higher level of wellbeing.
- Meditation is an alternative intervention that more and more therapists are incorporating into traditional psychotherapy. It involves intentional quiet time, often with a focus on breath. Regular meditation practices have been demonstrated to have a positive impact on psychological distress.
Potential benefits and Risks of depression
With any type of therapy (traditional or alternative/complementary), it is crucial to seek out a practitioner with appropriate credentials and a high level of competency. Some of these alternative treatments have more direct physical effects on the body, so an under-trained clinician could do harm to your body. Each type of treatment has a great deal of power, so wielded in an ineffective way, it can have unexpected or adverse effects.
However, if you find a trustworthy clinician, the positive effects of these complementary therapies can be dramatic. Either on their own, or in tandem with traditional therapy, they can empower the body to assist the brain in healing. When you are able to combine the power of your body and your brain, the results can be dramatic and positive.
Brain Stimulation Therapies in depression
- Electroconvulsive Therapy (ECT) is a medical procedure used for treatment-resistant depression or bipolar disorder. ECT happens in a hospital, while you are asleep. A trained physician, or team of practitioners, applies electrodes to your head, which send controlled electrical impulses that trigger a very brief seizure. The seizure stimulates the neurons and chemicals in your brain in a way that helps disrupt the patterns associated with your mental illness. After a few minutes, you wake up with no memory of the procedure. Generally, ECT is done two or three times a week for about six to 12 treatments total. The American Psychiatric Association (APA) reports that ECT provides symptom mitigation for up to 80% of patients that undergo the procedure.
- Vagus Nerve Stimulation involves an initial surgery to implant a small device (called a pulse generator) next to one of the two vagus nerves (a large nerve running from your brain to your stomach) in your body. After recovery from surgery, your doctors work to figure out the optimal frequency for stimulating your vagal nerve. The most common pattern is a 30-second stimulation every five minutes.
- Repetitive Transcranial Magnetic Stimulation (rTMS) is a procedure that uses electromagnetic pulses to stimulate your brain. Like ECT and VNS, rTMS is done by a doctor who holds an electromagnetic coil next to your head. You will hear/feel the pulses as “tapping,” and you’ll have to wear earplugs because the machine is quite noisy. Each procedure takes 30-40 minutes, and you generally undergo the procedure five days a week for about a month.
Effectiveness and Side Effects of depression
- ECT is generally quite effective, with the APA reporting symptom mitigation in up to 80% of individuals that go through it. However, on the day of the procedure, it is not uncommon to experience nausea, headache, confusion, fatigue, and temporary memory loss. If you are in the majority of people who experience relief from psychological symptoms, these temporary side effects may be a small price to pay for feeling better.
- Vagus Nerve Stimulation is a long-term treatment, so relief does not usually come quickly. A study in Biological Psychiatry showed that 27% of people undergoing VNS saw improvement in their depressive symptoms. Aside from the long duration of treatment prior to substantial improvement, the side effects are minimal and usually involve minor discomfort during the procedure itself.
- rTMS can be quite effective for depression, with studies generally showing that 50-60% of people who undergo the treatment report some improvement, and 30% of that group experience complete remission. The primary side effects during and right after treatment include headaches (treatable with OTC medication) and lightheadedness. Unfortunately, the improvement noted following rTMS is not always permanent, and the procedure may need to be repeated.
Brain stimulation therapies are often used when more traditional psychotherapy, or talk therapy, has proven ineffective. Sometimes depression that has not responded to other interventions is referred to as “treatment-resistant.” When this occurs, in a minority of cases, you may want to talk to your physician about somewhat more invasive brain stimulation techniques.