Depression is a state that affects mind, emotion and body, creating a dysphoric mood, lethargy or anxiety in the body, and thoughts of hopelessness, helplessness and, in a significant number of cases, suicidal ideation. Depression should not be confused with normal grief in the aftermath of a major loss, although extended grief may lead to true depression. Depression that is mild and chronic, with fewer symptoms, is known as dysthymia. Depression may present differently based on age or cultural factors. Adolescents tend to show an irritable and agitated depression; older adults may or may not be irritable; certain cultural groups may mask their feeling to varying degrees; women are known to be more likely to admit to depression than men. Depression is one of the most common reasons people seek therapy.
The Basics: Depression is a feeling of profound sadness, and/or poor self-image, and/or hopelessness and helplessness. It usually includes anhedonia and anergia (lack of pleasure and lack of energy), and may be irritable or agitated, meaning a dysphoric mood is present without lethargy.
Body: Those experiencing depression may have great difficulty mustering the energy necessary for even the most basic tasks, such as getting out bed, preparing food, or bathing. Depression often includes intense, unrelievable fatigue. Depression may be somaticized, leading to complaints about back pain, muscle aches, nausea, and headaches. Depression may lead to sudden tearfulness without an apparent trigger.
Mind: Depression always includes negative thoughts, sometimes with great severity. Individuals who are depressed may perseverate on thoughts like “I’m no good,” “no one cares about me, “life is pointless,” or “I’ll never feel better.” People with depression may have great guilt or shame, sometimes with an identifiable etiology, sometimes not. Worries are frequently present. In the most severe cases, thinking may be minimal, and the person with depression may border on a comatose state. Suicidal ideation is common.
Emotions: Depression involves the emotions of sadness and grief, and often anger, fear, shame, and other negative emotions. Affect may be strong, with tearfulness, tension, and possibly anger may be present, or affect may be restricted and in severe cases, flat.
Relationships: Depression usually interferes with a person’s ability to communicate, express emotion, and to experience emotional and sexual intimacy in relationships. A person who is depressed may be unable to receive comfort from others, believing they do not deserve it or it is insincere. Their lethargy, irritability, or anhedonia may make giving love near impossible. Depressed people often isolate; at the other end of the spectrum they may be overly dependent, attached, or needy. Depression may have passive-aggressive elements that disrupt relationships. Depressed people are often uninterested in normally pleasant social activities, and may be unable to work due to lethargy or fearfulness.
Correlations: Depression may co-occur with any other mental disorder, and is commonly linked with anxiety. Depression may alternative with manic or hypomanic states in Bipolar disorder or schizoaffective disorder. Depression is often linked to a lack of social support, recent loss, financial stress, and familial depression. Suicide risk is always a concern and must be assessed frequently. Depression must be distinguished from appropriate, short-term grief in the face of loss. Depression can be a major symptom of pos-traumatic stress. Depression is also associated with substance abuse, especially with alcohol and other central nervous system depressants. People may self-medicate with such substances to manage depression, making their symptoms worse in the long term.
Depression According to the Diagnostic and Statistical Manual of Mental Disorders (DSM):
Criteria for Major Depressive Episode:
A. Five (or more) of the following symptoms have been present during the same
2-week period and represent a change from previous functioning; at least
one of the symptoms is either (1) depressed mood or (2) loss of interest or
pleasure.
(1) depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad or empty) or observation made by others (e.g., appears tearful).
NOTE : In children and adolescents, irritability may be observed.
(2) markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation made by others)
(3) significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day.
NOTE: In children, consider failure to make expected weight gains.
(4) insomnia or hypersomnia nearly every day
(5) psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down)
(6) fatigue or loss of energy nearly every day
(7) feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick)
(8) diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others)
(9) recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide
B. The symptoms do not meet criteria for a Mixed Episode.
C. The symptoms cause clinically significant distress or impairment in social,
occupational, or other important areas of functioning.
D. The symptoms are not due to the direct physiological effects of a substance
(e.g., a drug of abuse, a medication) or a general medical condition (e.g.,
hypothyroidism).
E. The symptoms are not better accounted for by Bereavement, i.e., after the
loss of a loved one, the symptoms persist for longer than 2 months or are
characterized by marked functional impairment, morbid preoccupation with
worthlessness, suicidal ideation, psychotic symptoms, or psychomotor
retardation.
Case examples of Depression:
Tommy, a 21 year-old college student was referred to the university counseling center by his roommate who noticed Tommy was sleeping most of the day, missing class, and skipping meals. Tommy goes to his first appointment reluctantly, but because Tommy recognizes that he hasn't been the same lately, he agrees to keep meeting with his therapist. In therapy Tommy recognizes that his depression began immediately following the break up with his college sweetheart, Lynn, because Lynn was having feelings for another man. In future session, Tommy identifies feelings of grief, betrayal, and deeper down, hidden feelings of inadequacy. Tommy has a breakthrough insight when he discovers that his depression has been helping him avoid these painful feelings. The recognition itself helps the depression begin to loosen its grip. Tommy continues therapy for about a dozen sessions in which he identifies and cares for parts of himself that have felt inadequate since childhood. This increases Tommy's confidence and self-esteem and causes his depression to lift entirely.
Rudy, 38, cries and cries during the first interview with his new therapist, and cannot say why. His life is, on the surface, everything anyone could want. He is married with two healthy children, finances are not a problem, and he claims to love his job as a financial analyst – or at least that he used to love it. Lately, he does not seem to like, let alone love, anything. Sports, which once gave him pleasure, now seem empty and meaningless. He feels distant from his wife and family. His job feels pointless and tedious. He has also been drinking alcohol, secretly, to numb himself. Treatment reveals hidden feelings of guilt and shame about Rudy’s perceived inadequacy as a son and now as a husband and father. His rigidly punitive parents instilled in him perfectionism impossible to fulfill. Rudy has long buried his anger about this, and it takes a good deal of work for him to begin challenging his own rigid beliefs. Quitting drinking turns out to be easier than Rudy thought it would be once he is able to talk openly, with both his wife and his therapist, about his deep shame and fear. Rudy asks for medications and is given a referral to a psychiatrist who prescribes and SSRI. Rudy reports it helps him get through the work day, but after six months he decides the side-effects are not worth it, and as he has made good progress, his therapist and psychiatrist agree stopping would be fine. Though his mood diminishes for a few weeks, he is soon feeling more optimistic, closer with his wife, and more motivated at work.
Mindy, age 63, presents as depressed to the point of near delirium, verbalizing confused thoughts and a loss of focus and cognitive organization. She has no history of psychiatric treatment, but her partner reports she has always been somewhat gloomy and anxious. This episode is different, as she has been unable to work, tearful most of the day, isolative, and lethargic, which are totally out of character. An interview reveals that retirement looms ahead, a new boss has replaced one the client liked much better, and the client’s mother’s recent death has not been fully grieved. Treatment includes normalizing feelings of grief and identifying life-stage changes that triggered the diminished mood. After eight sessions Mindy is able to confront deeply held fears and beliefs, begin communicating better with her partner – who was not meeting her need for physical affection – and make a plan for her transition to retirement. Mindy’s depression abated and she returned to her job with more hope, if not enthusiasm.
Medical Model Approach to the Treatment of Depression: The Medical Model approach to the understanding and treatment of depression views depression as a disease. The most popular medical treatment of depression is medication. Several classes of medications have been developed to improve mood. All have a good chance of significant side-effects, in some cases including insomnia and sexual problems. For severe depression, medications can be helpful in stabilizing a person, helping one to get out of bed in the morning, and making talk therapy more effective. Medication can be a lifesaver, for those who have been considering suicide. However useful these medications may be at symptom reduction, they fail to address the emotional and psychological causes of depression, which often underlie the formation and maintenance of anxiety.
The Psychotherapy Model Approach to the Treatment of Depression: The Psychotherapy Model views depression as a normal response to human experience and survival. Rather than medicating the depression away as a permanent solution, the Psychotherapy Model approaches a person's depression with intense curiosity in an effort to help the person to understand and heal the source of the depression. Through the process of focusing internally a person can understand, unravel, and transform their depression. Psychodynamic approaches often view depression as a defense mechanism, a form of coping or self-protection which relies on "giving up" or "shutting down" to avoid greater emotional risk or pain (see case example: Tommy). And there are other psychological and emotional reasons for depression. Whatever the cause, depression can be improved, if not resolved completely, with therapy. Indeed, research shows that some people may be more predisposed than others to develop depression in response to life events. The familial inheritance identified in depression is both genetic and learned. Whether one is predisposed to depression or not, there is nonetheless a great benefit in addressing depression with therapy.
Therapy for Depression
There is a wide range of Psychotherapy Treatment Models or types of therapy used in the treatment of depression. Most of these approaches fall into three historic camps of psychology: Psychoanalytic / Psychodynamic approaches; Behaviorism and; Humanism. Regardless of the type of therapy, there are some generally agreed upon elements of "good therapy" which are universal to all forms of psychotherapy. Before beginning therapy for depression or any other issue, it is helpful to familiarize oneself with these elements.
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