Depression

Defined

As we experience hardships and challenges in life, it is common to experience periods of sadness and irritability that last a few days at a time. For some of us, however, those feelings persist. Instead of diminishing with time, they linger like a dark cloud despite our best efforts to move past them (Potter, 2020). 

Depression is marked by a mood that is consistently low, bringing with it feelings of emptiness, despair, hopelessness, or sorrow. Intense emotions like worthlessness, shame or guilt come to cast a shadow on how we perceive ourselves and the world around us (Potter, 2020). 

We may find ourselves losing interest in people or activities we once enjoyed. We may no longer be able to experience pleasure doing the things we used to seek out for that very purpose. We might feel fatigue throughout the day, and sleep excessively or face endlessly restless nights of insomnia, unpleasant dreams or early morning awakening (DSM-5). 

Our ability to think, feel and move our bodies can become clouded, blunted, slowed, agitated or anxious. It may become difficult to focus, make decisions, problem solve or remember things from the recent or distant past (DSM-5). We might struggle to find our appetite, or overeat ourselves into discomfort. We may lose interest in emotional, physical and sexual connectedness, isolating ourselves from those we love and neglecting our physical bodies (Potter, 2020).

Depression is known to have a vast number of causes. It develops through a combination of inherited genetic traits that are expressed during exposure to certain conditions or stressors as well as learned behavior (Potter, 2020). Across the globe, women are twice as likely to develop symptoms of depression during their lifetime (Weiner, 2010). 

Signs and Symptoms of Depression

Depression presents differently in everyone, and some of us have become experts at hiding our feelings of sadness. We may use humor to deflect others' attempts to connect or to lighten the mood, or we may throw ourselves into work or activities to keep ourselves distracted. There is no universal set of rules describing how a depressed person does and does not act (Potter, 2020).

Some may feel more comfortable expressing sadness as anger, engaging in outbursts of frustration that are disproportionate to the situation at hand. Some of us may become fixated on failures of the past, finding ways to blame ourselves for all the things we did and didn’t do. We might find ourselves tearing up at random moments, even when we don't quite understand exactly why (MFMER, 2018). 

It is possible we may experience unexplained physical symptoms that cannot otherwise be medically explained. Commonly reported symptoms include back pain, stomach pain, headache and body aches. A more severe symptom of depression involves frequent, intrusive and recurring thoughts of self harm, dying, or death in general (MFMER, 2018).

If you are experiencing thoughts of suicide, please connect with the suicide prevention lifeline by clicking here.

Depression has been known to present itself through substance abuse and misuse. When struggling, many of us attempt to self-medicate, and medications or illegal drugs may be used to help alleviate difficult to manage symptoms like anxiety, irritability and difficulties sleeping (Potter, 2020). 

Depression is currently diagnosed using a tool called the Patient Health Questionnaire 9 (PHQ-9), available below. When using this form, we are asked to consider how often we’ve faced specific challenges over the last two weeks, and the level of difficulty these challenges present (Weiner, 2010). Most doctors will ask that we use this tool on an every-other-week basis so we are able to track our symptoms and better understand if our treatments are effective.

How Depression Develops

Depression is passed down genetically, as well as through the behavior and coping strategies that our families teach us. If a first degree relative (parent, sibling, or child) has depression, we have between a 31% and 42% chance of developing it in our lifetime (Potter, 2020). 

There is no one single cause of depression, and the multitude of causes are thought to be interdependent and constantly fluctuating as we move through the phases of our lives (Weiner, 2010). Below is a list of the current theories describing how depression develops:

  • Stress and Trauma - When we experience unmanageable stressors or severe trauma (for example - financial hardships, emotional/physical/sexual abuse, or the loss of a loved one), our internal and external resources become quickly overwhelmed. Once exhausted, we may find ourselves struggling to cope and unable to identify positive future outcomes (MFMER, 2018).
  • Sociocultural Theory - This theory presents the idea that our socioeconomic status plays a significant role in the development of depression. To best illuminate this concept, consider the impacts that poverty can have on ideas about the self and the future. Social changes including the breakdown of family systems, the loss of loved ones, moving away from social supports, interactions with police, illnesses, and emotional exhaustion are all considered to influence mood and potentially trigger depressive symptoms (Brown, 2012). Caregiver burden, loss of independence or ability as adults, and marital dissatisfaction also influence depression within this domain (Potter, 2020).  
  • Cognitive Theory - Through this lens, depression is thought to originate in the way we talk to ourselves internally and about ourselves to others. Meaning that we may have developed a skewed self-concept or set of core beliefs about ourselves in our formative years, and use that negative way of thinking to assess ourselves today, experience our environment, and plan for the future. These altered perspectives are called cognitive distortions, and they can prevent us from seeing a path toward recovery while keeping us locked in a self-defeating headspace that can feel impossible to overcome (Beck, 1967). Common cognitive distortions include (Potter, 2020):
    • Catastrophizing - Assuming the worst outcome is always the most likely and exaggerating negative aspects of events.
    • Automatic thoughts - Negative core beliefs that we express as conscious thoughts without conscious intention.
    • Arbitrary inference - Focusing on the negative aspects of events, people or ourselves while discounting positive aspects.
    • Overgeneralization - Considering one isolated event as representative of all events.
  • Interpersonal Theory - This perspective on depression comes from the idea that there is a basic human need for interpersonal connection. Relationships provide a sense of attachment and security upon which we can build a positive sense of self. The thought of, or threat of, losing those relationships can cause anger and grief that grows over time. These feelings can sometimes cause us to push away loved ones and sacrifice intimate relationships to avoid a perceived future losses, leading us to isolate and worsen our depression (Verdeli, 2014). In addition, we may have unhealthy or unsupportive personal relationships that leave us feeling unfulfilled and in a way, starved, for emotional support (Potter, 2020). 
  • Learning Theory - When a negative event happens in our life, we use our past experiences and understanding to interpret the causes behind what happened and understand the role we played. If we have not had much success influencing events of the past, or have not had positive reinforcement of efforts made to influence events, we may come to apply that perspective of learned helplessness onto the future. This may lead us to give up easily because we think our efforts will not matter, which causes us to see ourselves as weaker than others and less capable. This external locus of control can leave us anxious, fearful and depressed (Halter, 2014).
  • Internalized Gender Roles and Gender-Based Expectations - This concept relates to all genders and captures the idea that meeting socially predetermined limits based on gender stunts the expression of the true self (Platt, 2016). Men may experience cultural expectations of stoicism and emotional repression. Trans gendered individuals may experience social displacement and lack of acceptance. Women may experience higher levels of sexual abuse, expectations of unlimited caregiving and self-sacrifice, and culturally enforced barriers to personal and financial freedoms (Potter, 2020). 
  • Biological rhythms - The physiological processes of our bodies regularly fluctuate over the course of 24 hours. This is known as our circadian rhythm. For some, there is a lack of synchronization of that rhythm, and such inconsistencies can strain the body and lead to feelings of depression. One example is that of seasonal affective disorder, where as fall ends and winter time begins, depression develops (Baron, 2014).
  • Hormonal differences - Those who are experiencing depression often have increased levels of stress hormones, specifically cortisol, even during times of safety. It is thought that the hormonal changes women go through as part of their menstrual cycles are part of why more women report symptoms of depression. Female sex hormones are important modulators of serotonin, norepinephrine and dopamine (Potter, 2020).
  • Inflammation - Research has shown that those who are depressed often have higher levels of cytokines (markers of inflammation) in their blood streams. The exact connection between inflammation and depression is not yet fully understood (Raison, 2011). 

Additional risk factors for depression include (MFMER, 2018):

  • Personality traits including low self-esteem, co-dependence, and pessimism
  • Being LGBTQ+ or having been born with intersex genitalia in an environment that is not supportive
  • Co-occuring mental health conditions including anxiety, eating disorders, or PTSD
  • Chronic or severe medical conditions

Major Depression in the United States

Major depressive disorder is the most commonly diagnosed mental disorder in the United States. The number of people expected to experience this condition at some point in their life ranges from 6% to 25% depending on the study and the population demographics (Weiner, 2010). 

Children younger than 13 years of age experience depression at a rate of 2.8%, and 13 to 18 year olds experience depression at a rate of 11%. Older adults living in communities experience a 5% rate of depression, while those living in nursing homes report rates of depression up to 42% (Potter, 2020). 

One episode of depression places an individual at a 50% increased risk for experiencing another episode in their lifetime (Potter, 2020).

Impact of Depression on Physical Health 

Depression often manifests itself through somatization, where psychological distress presents as physical symptoms. Those with depression frequently report headaches, chest pains, dizziness and feeling fatigued. This phenomenon is so powerful that those with depression are more likely to develop future medical complications (de Heer, 2014). Depressed individuals have a significantly higher risk of developing acute coronary syndrome than the general population (Ho, 2018).

Pain and depression have a reciprocal relationship. Meaning, being in pain can cause depression and depression can cause pain (Potter, 2020). Between 65% and 80% of individuals with depression report physical pain as a symptom of their condition (de Heer, 2014).

Depression can also lead us to neglect our physical health and personal hygiene. This can lead to severe physical deficits that increase the risk of infection, disease and social isolation (Stewart, 2021). Depression is the leading cause of disability worldwide (Potter, 2020).

Strategies to Overcome Depression

Cognitive Behavioral Therapy (CBT) uses a short term, goal oriented perspective focused on identifying, challenging and altering damaging patterns of thinking, maladaptive attitudes, and internally held beliefs that exacerbate symptoms. Once such patterns of thought are identified, CBT offers a time constrained, structured strategy to replace them with more constructive thoughts which then encourage more constructive behaviors (Potter, 2020). For access to a free version of CBT, click here.

Similar to CBT, Interpersonal Therapy (IPT) works by supporting us as we identify the difficulties we are having within our important personal relationships and develop coping strategies to resolve them. Difficulties may include role transitions, role conflicts, and the need for more effective social skills (Weiner, 2010). This strategy offers a highly structured, time-limited and practical approach to current interpersonal events (including disputes and processing grief), with the goal of improving communication, meaningful expression, and renegotiating the roles we take on (Potter, 2020).

Another strategy related to IPT is assertiveness training. This approach focuses on how we express ourselves when we are trying to get our needs met. Instead of being aggressive (ruthlessly seeking what we want without considering the needs of others) or passive (avoiding conflict to the point of sacrificing our own happiness), we instead develop our assertive voice. One where we express our thoughts, desires and opinions in an effort to meet our needs, without sacrificing the needs of others (Eslami, 2016).

CBT, IPT and antidepressant medications have all been shown to be equally as effective in the long term treatment of depression. 50% to 65% of individuals surveyed reported a significant reduction in depressive symptoms after using one of these treatments (Weiner, 2010). 

Depression can also be managed effectively through the identification and development of protective factors that help maintain an elevated mood. These include connectedness to our friends, family and community, access to mental health care and healthy coping strategies (Potter, 2020). For access to a list of ways to build protective factors, click here.

The development of problem solving strategies, life skills, direct communication and internal/external resources like resiliency also serves to insulate us from depression (Stefaniak, 2022). For more information on resiliency and how it can insulate us from depression, click here.

A specific diet has been recommended for those experiencing the physical changes caused by depression. To prevent inflammation, it is recommended that we avoid sugar, saturated fats and refined or highly processed foods. Diets high in fruits, vegetables, beans, whole grains and fish offer access to nutrients that have protect factors, including omega-3 fatty acids, folic acid, vitamin D, selenium and calcium (Roca, 2016).

Getting an adequate amount of sleep and engaging in physicality, specifically mind/body connectedness and movement, can help reduce symptoms of depression (Gobin, 2015). For more insight into physicality strategies, click here.

Reducing the amount of time spent smoking also has a direct impact on alleviating symptoms of depression (Jacka, 2012).

Light therapy (using a broad spectrum light for at least 30 minutes a day) has been shown to reduce the symptoms of certain forms of depression (Even, 2007). 

There is also a proven psychological benefit connected to a belief in a higher power, an afterlife, and fate. These beliefs are thought to create a sense of meaning around events, offer comfort in times of illness and crisis, and provide guidance when we are unsure of how to move past difficult moments in life in a way that aligns with our morals and values. Additionally, spirituality can increase our access to social support systems that can help us during hardship (Potter, 2020).

For Help Now With Depression

If a worsening level of depression is beginning to form, the first step is to ensure personal safety. This means removing weapons or medications from our environment, or removing ourselves from unsafe places or people. We need to reach out immediately to those who we feel safe around and trust, and seek professional medical treatment. If we cannot cope with thoughts of self-harm, it is imperative that we call one of the following crisis lines immediately (MFMER, 2018):

National Suicide Prevention Lifeline

  • Call 988 or 800-273-8255
  • TTY users please use your preferred relay service or dial 711 then 1-800-273-8255

Nacional de Prevención del Suicidio

  • Telephono 888-628-9454

Crisis Text Line

  • Text NAMI or HOME to 741-741

Supporting Someone Who is Experiencing Depression

One of the most important things we can do to support someone we know who is experiencing depression is to understand the condition. Knowing what depression is, and is not, will allow us to engage those we care for with a higher level of empathy and understanding (MFMER, 2018). The information presented on this web page can offer such insight. Please feel welcome to share it with those who need it most.

Those we care about may not recognize that their feelings of depression are harmful to themselves and others, and that there are alternatives to daily suffering. It is reasonable in these cases to share our concerns with those suffering from depression, where we let them know they are loved, supported and have nothing to be ashamed of (MFMER, 2018).

Depression is a medically recognized condition and there are treatment options available. Beyond the strategies presented here, there are medication therapies available that have been proven effective as well as therapy options best delivered by a mental health professional. We can help those we care about by supporting them as they take the steps needed to connect with those who are in the best position to help them (MFMER, 2018). 

It is important to remain alert to worsening depression and the risk of suicide. Warning signs of suicide include (MFMER, 2018):

  • Talking about death or suicide
  • A preoccupation with death or suicide
  • Making active plans to attempt suicide including buying a gun or ammunition
  • Withdrawal from friends and family
  • Mood swings and intense highs and lows
  • Personality changes including severe anxiety or agitation
  • Feelings of being trapped or hopeless
  • Increased use and abuse of substances
  • Changes in normal routines, eating patterns and sleeping patterns
  • Taking extreme risks or engaging in self destructive behavior
  • Giving away belongings, planning their funeral or organizing their estate
  • Saying goodbye to people and loved ones with a sense of finality

If you are worried that someone you know is suicidal or homicidal, please click here.

When working to help someone with depression, it is critical that we make an effort to take care of ourselves as well. We are not able to help others when we do not have the internal resources to do so. To prevent burnout and frustration, we are well served by reaching out to those who can support us. We should make time for ourselves and our hobbies, and take breaks from the depressed person to recharge our energy. Getting enough sleep, eating healthy foods, drinking enough water and engaging in physicality should be prioritized (MFMER, 2018). For more strategies we can use to cope with a loved one experiencing depression, click here.