“In the past when my father was diagnosed with cancer, it made me more focused, more dedicated, more connected to him. I was the best version of myself then. Now, I feel so frail. I don’t feel like my normal self.”
“I feel like I’m always one step removed.”
“I actually don’t feel sad. I don’t feel anything. I know that this should feel good, but it doesn’t.”
“I can’t get out of bed, even though a part of me knows that if I get out of bed, I’ll probably feel better. But I can’t get up.”
These are all ways in which people in my practice have described what they’ve felt during seasons of Depression. What they all have in common is that when they were depressed, they didn’t feel like their normal selves. I sometimes use this self-awareness to help people understand that this unfamiliar state only reinforces that what they are experiencing is indeed a clinical Depression, and not a “normal” reaction to difficult circumstances. This is one of the most valuable insights that I learned from one of my mentors during residency – that there’s “misery” which we’re all bound to experience at some point in our lives, and then there’s Depression, and they are not the same.
I’ve previously discussed the important role of emotions as it pertains to motivation, health and wellbeing – and this includes the value of unpleasant emotions. Some of these feelings that may not feel so great are necessary to help provide us the awareness and in turn the motivation to help course correct our behavior back towards healthiness. For example:
Feelings of misery cause us to reflect on our negative circumstances and eventually create an internal tension so great that it creates a willingness to take the risks necessary to make meaningful changes in our lives.
Feelings of sadness are experienced when we’ve suffered a loss, and the process of grieving allows us to appreciate what we have, and take inventory of what is needed to move forward.
Feelings of loneliness help us to recognize our universal need for connection, creating an internal sense of longing, which builds a motivation to fulfill our relationship needs by seeking out opportunities to reach out to others.
All of these experiences are emotionally painful, but just like physical pain, they alert us to problems in our lives, and provide motivation and direction to attempt to resolve these issues. All of these experiences are also normal parts of our shared human experience. 100% of us will experience misery, sadness, and loneliness at different times throughout our whole lives, and if we respond appropriately, it’s a good thing.
Depression is different. Though certain emotions can feel depressing, a capital “D” Depression (or formally called a Major Depressive Episode) is a prolonged state of dysfunction, outside the scope of normal human experience. It is more common than most people think. About 7% of the American population will experience a Major Depressive Episode in any given year, but most people will not experience depression in their lifetime. However, it is common enough that you are very likely to know someone within your inner social circle that has experienced Depression, or you yourself may be that person. In fact, even by conservative measures, about 1 in 8 women will experience a depressive episode in their lifetime, which is about the same percentage of women who have been diagnosed with breast cancer. For men, the risk over a lifetime is about 1 in 15. To make these statistics more realistic, take the average sized class of 30 students. Two of the boys and four of the girls in that class will have Depression in their lifetime.
Another very important distinction between unpleasant emotions and Depression is related to the source of the feelings. Whereas normal emotional experiences are a natural response to circumstance (outside factors), the symptoms of Depression are caused by internal factors within the brain. For example, a person feels miserable because they have an ungratifying, underpaying job that they spend 70 hours a week at. Outside-in. Depression causes a person to believe that their previously perfectly acceptable job is now overwhelmingly difficult and stressful. Inside-out. Healthy emotions are also responsive to acute changes in environment. If a person is understandably feeling sad and lonely because of a recent breakup, some caring friends might be able to temporarily cheer him up by taking him out and providing good company to get his mind off of things. If a person is depressed, regardless of a change in environment or the presence of other positive relationships, this person still feels empty, disconnected, and is unable to enjoy themselves. If someone hates their job but goes on a two week vacation to Hawaii, they can have fun and relax while away, and will likely start feeling bad on the return flight anticipating their first day back to work. With Depression, that person still feels depressed in Hawaii, again because it is the internal state of mind that dictates their mood.
Depression is also much more than an emotional problem, but a reflection of the expansive dysfunction of the whole mind, where its symptoms reach into all the primary domains of brain functioning – including the physical, cognitive and emotional. In fact, when looking at the core symptoms of Depression, we can see that they are divided into these three categories:
Physical – changes to appetite, changes to baseline sleep patterns, changes to energy levels, changes to motivation and drive
Cognitive – concentration problems, memory difficulties, negative thinking patterns (hopelessness, helplessness, worthlessness)
Emotional – inability to regulate mood properly, diminished ability to experience positive emotions, excessive feelings of guilt
A simpler way to think of how best to summarize these changes are that all brain functions are diminished during a depressive episode, and the above symptoms are the manifestation of that diminished functioning. Some symptoms are a result of losing the regulatory functions of the brain, such as with disturbances in sleep, appetite, and mood. Other symptoms are the direct result of impaired functioning – such as a lack of positive emotion, slowed thinking, low energy and drive. These core dysfunctions of the primary abilities of the brain lead to secondary impairments in social, occupational and the otherwise normal routines of daily functioning. The severity of impairment is usually a combination of symptom severity along with the degree to which cognitive distortions affect a person’s behavior. Depression by itself feels bad enough, but if a person is convinced that they can’t get out of bed, isn’t eating much, isolates, and recycles negative thoughts in their head all day long – they will feel worse. The most dangerous outcome of such distorted thinking is the triad of feeling hopeless, helpless and worthless – paired with the genuine anguish of Depression. This commonly leads to passive thoughts of dying as a form of relief to their suffering, and at its worst can lead to persistent thoughts of suicide. However, it is crucial to know that full recovery from depressive episodes is the norm, and so suicide would be an even more tragic attempt to find a permanent solution to temporary pain. With Depression, it will always resolve and recovery is usually complete.
As described above, the symptoms experienced during Depression are a reflection of problems of brain functioning, not related to brain injury. To use a modern analogy, if your brain was a computer, it’s more akin to a software problem, not a hardware issue. Once the software bug has been fixed, you can usually expect the computer to run as well as it did before. Talking about fixes, the good news is that Depression is readily treatable and most people respond positively. One big reason has to do with its episodic nature to begin with – there’s a beginning, and thankfully there’s an end. These episodes can last for a couple of weeks, or more commonly for few months. But almost always, they end. So in one sense, the most reliable “treatment” for Depression is time. However, there’s a lot of suffering during a Depression so all active treatments are therefore aimed at effectively reducing the severity, intensity, duration and recurrence of symptoms.
The most common options for treatment are the use of medication or structured talk therapy, the most studied and practiced being Cognitive Behavioral Therapy (CBT). Many studies validate that the combination of the two tends to better than either alone. Beyond that, there’s also procedures that can be done for more severe cases, including rTMS and ECT. From the perspective of Mental Healthiness principles, I’ve previously discussed specific ways in which research has demonstrated that positive relationships, growth mindsets, and strategies that support self-efficacy also can be effectively used to not only treat a depressive episode, but also contributes to greater mental health in the long term, providing greater protection against future recurrence as well. To read more, click here.
Misery, sadness, and loneliness are universal experiences of our human lives. Like all emotion, when we learn to recognize and effectively use them, they provide us healthy motivation and direction to resolve our problems and meet our needs. This is good. This is healthy. Depression is not good nor healthy. It is an experience that in some ways can feel like these normal emotional states, but in every other way is more painful, dysfunctional, and reflects an unhealthy state of mind. Thankfully, there’s many helpful and safe ways to accelerate the process of healing when depressed, and people always recover because depression comes and goes like the seasons. Winter inevitably ends and leads into the Spring. If you think that you or someone you care about may be experiencing Depression, reach out to someone and get help, because it will do just that – it will help.
In the next entry in this Mental Health Month series we’ll discuss the often misunderstood Bipolar Disorder – what it is, what it isn’t and how positive relationships can make a huge difference in the life of a person with this condition.