1 The experience of depression
The main forms of depression and related conditions are summarised in Box 1. Diagnostic criteria also distinguish between less severe and chronic forms of depression. Treatment-resistant depression and dysthymia are defined in Box 2. We will look at diagnostic criteria later on, but the information provided here should serve as a useful reference as you read further and engage with the activities in that follow.
Box 1 Depression and related conditions
(based on NIMH, 2015)
Major depression involves severe symptoms that interfere with the ability to work, sleep, study, eat, and enjoy life. An episode can occur only once in a person’s lifetime, but more often, a person will experience several episodes.
Persistent depressive disorder is where depressed mood lasts for at least two years. A person diagnosed with persistent depressive disorder may have episodes of major depression along with periods of less severe symptoms, but symptoms must last for two years.
Other forms of depression include:
Psychotic depression, which occurs when a person has severe depression plus some form of psychosis, such as having disturbing false beliefs or a break with reality (delusions), or hearing or seeing upsetting things that others do not (hallucinations).
Postpartum (postnatal) depression, which occurs in around 10-15% of women after childbirth, and is more serious than the ‘baby blues’ that new mothers may experience after giving birth.
Seasonal affective disorder (SAD) is characterised by the onset of depression during the winter months, when there is less natural sunlight. The depression generally lifts during the spring and summer. SAD can be treated with light therapy, but nearly half of those with SAD do not get better with light therapy alone, and will require antidepressant medication and psychotherapy to reduce symptoms.
Bipolar disorder is also sometimes called ‘bipolar depression’, but the condition is different from other forms of depression− someone with bipolar disorder will typically experience episodes of extremes of mood (highs and lows) as well as symptoms of psychosis (delusions, hallucinations, disordered or disorganised thoughts).
Box 2 Treatment-resistant depression and dysthymia − definitions
Treatment-resistant depression* typically refers to depression which does not immediately respond to ‘standard’ treatment with antidepressant drugs (but note that drug treatment is only one of the therapeutic options available for depression). Depression is termed ‘treatment-resistant’ if two trials of drug treatment, each at an adequate dose administered over a sufficient course (period of time), have had no beneficial effect. This definition too is partly arbitrary, however; more specific definitions grade treatment resistance according to the number of failed treatment attempts.
Dysthymia according to ICD-10, is a state consisting of a depressive syndrome, lasting for several years, with lesser severity than in depression as strictly defined (including chronic or ‘major’ depression). The once separated diagnoses of ‘dysthymia’ and ‘chronic major depression’ have been grouped together in DSM-5 on account that ‘diagnostic and therapeutic differences between the two entities’ were deemed ‘too small to warrant separate classification’ (Bschor et al., 2014).
NOTE: (*) The time at which depression becomes ‘chronic’ by definition has been set, more or less arbitrarily, at two years. Chronic and treatment-resistant depression present the same symptoms as an acute depressive episode, but the following tend to be most prominent: low affective variability, anhedonia (an inability to find pleasure in activities one would normally find pleasurable), lack of drive, social withdrawal, lack of self-esteem, hopelessness, loss of libido, sleep disturbances, cognitive impairment and chronic suicidality.
Activity 1 The experience of depression
Watch the video below and consider the questions that follow. You might wish to view the entire recording first and then watch the video again thinking specifically about the questions the second time around, or you can review the questions as you watch the video from the start. Choose whichever approach suits you best.
In this moving and eloquent talk given in 2013, Andrew Solomon, Professor of Clinical Psychology at Columbia University, and author of The Noonday Demon: an atlas of depression (Andrew also writes regularly for The New Yorker and the New York Times), describes his personal experiences of living with depression, recounts the stories of others he has come into contact with, and describes how he has come to terms with depression.
Andrew explains that he had always thought of himself as being tough, as ‘one of the people who could survive if[he]had been sent to a concentration camp’ as he puts it. What triggered his depression?
How does he describe his depression?
Andrew also experienced anxiety. How did his anxiety develop and how long did it last?
When his depression became severely disabling, Andrew managed to seek help and started with medication and therapy. What does he consider as his two advantagesgoing'into the fight’?
He describes the relentless relapsing and remitting course of his illness. How did Andrew come to terms with his depression at the time?
He points out that people tend to confuse depression, grief and sadness. What important distinctions does Andrew make?
Andrew set out to understand depression, to find out what causes some people to be more resilient than others, and to know what mechanisms allowed people to survive. He gives the example of his friend Maggie Robbins, a poet and psychotherapist. How did Maggie experience depression? What thoughts did she and others experiencing depression typically have?
What therapies for depression does Andrew describe?
Andrew says that he was struck by the fact that ‘depression is broadly perceived to be a modern, Western, middle-class thing’. He touches upon cultural views on depression and different approaches to treatment, talking about his visit to Senegal and Rwanda. How does he describe some of these differences?
Through researching Andrew says that he has discovered that ‘depression is the result of a genetic vulnerability, which is presumably evenly distributed in the population, and triggering circumstances, which are likely to be more severe for people who are impoverished’, but that this is not being picked up, treated or addressed. What explanation does he give for this?
How does Andrew respond to questions like ‘Isn’t depression part of what people are supposed to experience? Didn’t we evolve to have depression? Isn’t it part of your personality?’
What is his response to whether depression is 'continuous with normal sadness'?
What does Andrew think is the main mechanism of resilience?
Andrew says that he had a series of losses in 1991. His mother died, a relationship he had been in ended. He moved back to the USA after being abroad and then three years later he found himself losing interest in almost everything. He didn’t want to do any of the things he had previously done, and he did not know why.
Everything he did seemed to involve so much work. He seemed to think about and view things differently. He gives an example of messages left by friends on his answering machine, and instead of feeling thrilled to hear from them, he would think to himself ‘what a lot of people that is to have to call back’. Carrying out everyday things such as having lunch would become a burdensome task – he would think about having to ‘get the food out and put it on a plate and cut it up and chew it and swallow it’. And he knew ‘it was ridiculous’ while he was experiencing these thoughts, and should not be a big deal, but when in its grip ‘unable to figure out any way around it’, so he began to feel himself doing, thinking and feeling less, which he describes as a kind of ‘nullity’.
Andrew talks about his acute anxiety ‘setting in’ after his initial bout of depression and lasting for six months, as a ‘sensation of being afraid all the time, but not even knowing what it is that you are afraid of’.
First, Andrew notes that ‘objectively speaking he had a nice life and that if he could only get well, there was something at the other end that was worth living for’. The second advantage was access to good treatment.
Andrew says that while thinking about biological (chemical), psychological or philosophical explanations for his depression, he also came to the understanding that it was ‘braided so deep into us that there was no separating it from our character and personality’.
Andrew notes that grief is explicitly reactive, and gives the example that if a person experiences loss, feels incredibly unhappy, and then six months later, they are still deeply sad but functioning a little better, it is probably grief which will ‘probably, ultimately, resolve itself in some measure’. If a person experiences a catastrophic loss, feels terrible and six months later can barely function at all, then it is likely to be depression triggered by the catastrophic circumstances. He defines depression as not simply ‘sadness’, rather ‘much too much sadness, much too much grief at far too slight a cause’, and that importantly the trajectory of the illness tells us a great deal.
Maggie had bipolar disorder (previously called manic depression), and coming off her medication plunged her into severe depression. Andrew describes her as sitting in her parents’ apartment ‘more or less catatonic, essentially without moving, day after day after day’. He recalls at the time of interview Maggie describing thoughts in her mind telling her ‘you are nothing. You are nobody. You don’t even deserve to live’, leading to thoughts about suicide. He describes other people living with depression having similar thoughts: ‘no one loves me’ or ‘no matter what we do,we’re all just going to die in the end’ or ‘there can be no true communion between two human beings. Each of us is trapped in his own body’. Andrew emphasises that depression can be exhausting and lack of communication about it could make things worse: ‘it takes up so much of your time and energy, and silence about it really does make the depression worse’.
Andrew mentions medication, psychotherapy, electroconvulsive treatment, meditation and even relatively simple things that could be done to lift someone’s mood or that they would do to make themselves feel better. He also describes the moving story of Frank Rukosoff, who underwent quite a radical surgical therapy (called a ‘cingulotomy’) to remove a small portion of brain tissue from his frontal lobe, after everything else he had tried had failed. Remarkably, his treatment was successful.
Andrew refers to a tribal exorcism in Senegal, how rituals differ between East and West Africa, and how the practice of Western mental health workers can be viewed differently as relayed to him in Rwanda, which he recounts in a lighthearted way: ‘Well, they would do this bizarre thing. They didn’t take people out in the sunshine where you begin to feel better. They didn’t include drumming or music to get people’s blood going. They didn’t involve the whole community. They didn’t externalise the depression as an invasive spirit. Instead, what they did was they took people, one at a time, into dingy little rooms and had them talk for an hour about bad things that had happened to them’.
Andrew says that if someone has a lovely life but feels miserable all the time, they would think ‘Why do I feel like this? I must have depression’ and they would set out to find treatment for it. If life is awful all of the time and the person also feels miserable all of the time, the way they feel would be commensurate with their life and it wouldn’t occur to them to think that maybe it could be treated. Note that this is one interpretation only, but it does draw out an important view, and touches not only on societal views but stigma as well.
Andrew says that mood – the ability to express sadness, fear, joy and pleasure − is adaptive, and major depression is what happens when that system gets broken. It becomes maladaptive.
Andrew agrees that there is a certain amount of continuity, but then gives an example using an iron fence analogy, where severe depression is an extreme form similar in his comparison to leaving the fence untended for 100 years until all that is left is ‘a pile of orange dust’.
Andrew believes that people who tolerate, can come to terms with and learn from their depression are the ones who achieve resilience. Those who deny their experience, shutting out their depression, strengthen it. He notes that:‘Valuing one’s depression does not prevent a relapse, but it may make the prospect of relapse, and even relapse itself, easier to tolerate. The question is not so much of finding great meaning and deciding your depression has been meaningful. It’s of seeking that meaning, and thinking, when it comes again "This will be hellish, but I will learn something from it".’