Monday, September 6, 2010

On Depression

If you have been feeling consistently sad or had trouble with your sleep or appetite, you may have asked yourself: "Might I be suffering from clinical depression?"

One of the confusing aspects in talking about depression is that we use the same word to describe both transient feelings of sadness ("My friend hurt my feelings. I'm so depressed.") as well as to describe a serious illness. Depression robs life and relationships of vitality and may even impair the ability to function capably in daily tasks.

Several people who have weathered painful and serious illnesses or losses have told me, "nothing was as bad as having depression." Perhaps we should invent a new word to describe the clinical illness of depression. I think this hasn't been done because, from the experience of the milder and brief periods of sadness that most of us have had, we have an intuitive appreciation of what the more severe forms might be like. The term "depression" is just too descriptive to let go.

Depression is probably a number of different illnesses which our science is not yet advanced enough to distinguish. You have probably heard the list of symptoms: Persistent sadness, change in sleep and appetite, loss of interest in your surroundings, difficulty experiencing pleasure, tiredness, and feelings of worthlessness and guilt. Sometimes thoughts of suicide may occur and these must always be taken seriously.

We think that depression has a physical or chemical imbalance basis. Because it often runs in families, we also believe that the tendency to suffer from depression may be inherited. Although the exact chemical changes are not fully understood, it appears that imbalances in the brain's mood-regulating chemicals – called neurotransmitters because they carry chemical messages between nerve cells – are responsible. You may have heard the names of some of them – serotonin, norepinephrine, and dopamine.

When we treat depression, we are treating the brain. There are several ways we have of doing this in an effective manner. Groups of nerve cells deep in the brain produce the mood-regulating neurotransmitters which, in depression, are in short supply. We use medications called antidepressants to increase the available amounts of neurotransmitter chemicals, thereby alleviating depression symptoms. Because neurotransmitters, after they are manufactured, are sent to most parts of the brain, their effects are general.

Suppose there are patterns of thinking and feeling that initiate or sustain symptoms of depression. When Joan was ten, her mother, who was afraid she was getting fat and would never be pretty or popular with boys, put her on a strict diet. She also often communicated her worry to Joan that she was gaining too much weight. As an adult Joan, attractive and of average build, sees herself as fat. She is ashamed of and depressed about her appearance. She withdraws from relationships and feels lonely, and her isolation perpetuates her depression.

We use psychotherapy, also called therapy, counseling, or psychoanalysis, to treat patterns of thinking and feeling that cause or contribute to depression. By talking with a therapist, these particular depression-producing patterns, residing in circuits of the brain, can be identified and favorably modified. The influence of therapy is specific, as compared to the more general influence of antidepressant medication. Therapy actually changes the brain. Circuits that contain the harmful patterns recede into the background, and new circuits containing more adaptive, healthy ways of thinking, can be developed. In Jack's case, through his therapy treatment, he came to perceive himself more accurately as an intelligent and capable person, likely to succeed on his job and in other aspects of life if he tries.

When do we use therapy and when do we use medication? Occasionally, the inherited predisposition to depression is severe, and symptoms are intense. There may not be much in the way of dysfunctional thought patters or even current stressors in a person's life. This picture of depression is something we view primarily in biological terms, and the treatment emphasizes medication. In this instance, talk therapy is useful to support, encourage, and educate the patient during the time the biological treatment is taking effect.

At times, symptoms may be milder. A person continues to function well enough, but she experiences little pleasure in life. Precipitants may be obvious, and negative thoughts and feelings about the self predominate. Here, although medication may also be useful, the emphasis is on the psychotherapy component. We want to change some aspects of the way the patient thinks and feels about herself. Therapy will be hard work, but the benefit can be great: lessening the possibility of future episodes of depression, and gaining more satisfaction in living.

Most often, the treatment of depression involves both directly influencing the brain's chemical imbalance through the use of antidepressant medication, and the changing of dysfunctional thoughts through talk therapy. If someone has suffered from depression for a long time, the illness itself may have had an effect on the way a person feels about himself. A psychiatrist, along with his patient and after a thorough evaluation, will recommend how much of each method should be used. The important thing to remember is that both methods treat the brain.

This article was originally posted in 2006 on