DEPRESSION

One of the difficulties we face in understanding depression arises from the fact the word itself has different meanings.  This creates ambiguity as to whether it is being used to describe a medical condition or circumstantial sadness that naturally arises for all of us in life.  In either case, we all understand "depression" to mean sadness.  But the term does not provide information about its cause. There are times when it is quite natural for us to be depressed in a non-medical way, and this is by far the most common type of "depression."  For example, a medical disease does not account for our profound depression or sadness when we lose something or someone dear to us.  

 

In contrast, there is a "depression" that is not necessarily dependent on  life circumstances. This form of depression is often the result of an independent medical illness.  Most commonly these medical illnesses are called Mood Disorders.  They come in one of two forms: Major Depressive Disorder or Bipolar Affective Disorder.  So, since the term "depression" is not specific enough to clarify causation or whether a disease is present, how do we go about doing so?

 

As suggested above, one form of "depression" is a normal mood state that is most often associated with one's circumstances at the time.  The other is characterized by a depressed or altered mood with additional signs and symptoms, none of which are necessarily dependent on one's life circumstances. Thus non-medical “depression” tends to describe a transient, reactive mood state.  We generally use it to describe sadness, loneliness, or disappointment.  It is most commonly tied to difficult life experiences that arise from ongoing or recent events. Sometimes it may be a normal case of the "blues" of short duration which all of us experience from time to time -- even if there isn't an obvious cause.    

 

In contrast, depression as a medical condition (which for simplicity we will distinguish using the capital letter D) is the result of medical diseases.  These diseases are most commonly Major Depressive Disorder or Bipolar Affective Disorder.  In this form, Depression is characterized by a more comprehensive collection of symptoms that can have more pervasive and debilitating effects.  This is not to say that natural depression is never terrible, overwhelming, or debilitating.   However, in its medical form, Depression involves additional physical and emotional changes that may compromise our daily experience through more comprehensive or pervasive impairments.  

 

So, as mentioned, the difference between depression and Depression is not measured by how sad or upset an individual becomes.   It is more the extent to which Depression's poison insinuates itself into so many aspects of a person's life.  To make matters worse, a single Depressive episode can have a more substantial duration --  from weeks to years.  

​

The specific signs and symptoms of Depression include both physical and "mental" changes.  There are several possible physical manifestations of Depression.  These may include a significant loss of energy --   feeling tired most of the time and lacking motivation.  There are usually sleep and appetite disruptions.  Often there is physical pain or an amplification of preexisting pain.  New pain is often described vaguely and can be difficult to localize.   This can create difficulty in finding the source, and frustration may develop in the Depressed person and their caregivers.  The person may be accused of "acting like a baby" or of complaining just "to get attention."  For some reason, pain becomes a more common symptom of Depression as we age.   

 

Other physical symptoms can be increased sensitivity to noise or other forms of stimulation.  Almost always, there is a slowdown in thinking and movement.  A depressed individual may walk, talk, and move more slowly or with greater hesitancy.  A slowing of function and clarity of the mind may present, and sometimes people can become so slowed down that they barely move at all and may become mute. This is sometimes referred to as catatonia.

 

There are also symptoms that do not present with purely physical manifestations.  There are fundamental disturbances of core beliefs and perceptions.  Beliefs about our own value or the value of life generally become distorted.   We may believe we are a burden to others, inadequate, inferior, worthless, or simply a failure.   Life may seem more meaningless or cruel. Often there is a perception that no one cares.   With this cluster of symptoms (and others), sometimes people will develop existential crises or crises of faith.  

 

We may experience also a shift in how we perceive and interact with the world. Almost always, there is a prominent loss of interest in much of anything.  Activities that were generally fun or pleasurable for the individual do not bring the same joy or fulfillment.  The same activities may seem pointless or even irritating. The person will often feel so tired and discouraged that these activities seem like a chore.  

​

Due to this disinterest and dwindling energy, affected individuals struggle to find enthusiasm for most if not all aspects of their lives.   There may be a strong desire to isolate and not participate socially.  Much of one's time will be spent alone in the bedroom hoping to sleep and escape Depression.   Difficulty getting out of bed or attending to important functions is common.  Straightening up the living space, keeping up with laundry, attending to the dishes or trash, or bathing and grooming may become overwhelming or almost impossible.   Outside activities or responsibilities are frequently avoided, family interactions minimized, and invitations to spend time with others will be rejected.  Involvement in group projects, sports, or clubs will be avoided or left altogether.  Adolescents may decide to quit a team or club about which they were previously quite enthusiastic.   At all age levels there may be atypical absences from work or school, poor grades, jobs lost or left, and lost friends or partners.

​

Unfortunately, others may misinterpret the behavior as laziness, lack of ambition/willpower, attention seeking/selfishness, weakness, incompetence, thoughtlessness, or passive-aggressive behavior.  There may be hurt or anger felt by others if they (understandably) misinterpret the Depressed person's behavior as disinterest and avoidance.    To make matters worse, others may become still more negative because Depressed persons frequently answer questions vaguely or with a simple "I don't know."  The impression may be that the vagueness reflects evasion or avoidance of accountability.    In fact, the vagueness reflects impaired concentration and mental slowing caused by the Depression.  

​​

With regard to mood changes, they are substantial; however, "depression" may not be the predominant mood.  There may be irritability, anxiety, or a loss of a mood altogether.  There is often a sense of guilt or shame.  Often the experience is likened to feeling as if one is trapped in a dark cave or hole from which there is no escape.  There may be  sense that the entire human experience has lost any vibrancy.  There may be a sense that the world - colors, tastes, emotions - have become blunted or grey.  

 

People may become tearful at “the drop of a hat.”  A commercial, song, or photo may trigger tears.  Not everyone becomes tearful, but this symptom is commonly present.  Possibly the most distressing mood or attitudinal change is the deterioration of hope.  Hopelessness might be the most destructive symptom of depression; certainly it is a hallmark of deepening Depression and despair.  It is a significant risk factor for suicide.

​

Finally, as noted above, there are prominent changes in the mind's ability to process information ("cognition"). Without fail, Depression diminishes concentration.  Poor concentration has pervasive, negative consequences on our ability to manipulate information.  With poor concentration, one's ability to attend to important information deteriorates.  People will have trouble following conversations or absorbing written material.  Poor concentration creates impairment of memory. Things will be forgotten and commitments overlooked. Some may misinterpret the changes as symptoms of new onset dementia.  This is so common that we sometimes use the term "pseudo-dementia" to describe new memory changes that are caused by Depression (instead of true dementia from diseases such as Alzheimer's Disease).

 

Depression and Psychosis

Up to 10% of persons who are in the midst of a depressive episode will develop a more significant shift in perceptions and beliefs.  The perceptions will no longer be rooted in reality.  These symptoms are referred to as "psychosis." Although there can be other symptoms of psychosis, for purposes of our discussion, the term is best understood as delusions and/or hallucinations.  

 

Hallucinations are distortions of our five senses.  Common hallucinations include voices that one perceives when no one is there.  Sometimes the speaker is recognizable to the person, but sometimes the source may be perceived as strangers or evil entities.  Other auditory hallucinations may be of a knife sharpening, a match lighting, scratches form something that seems to be in the walls or attic, or knocking on the wall or door.   When voices are involved, they almost always say very negative things and encourage mistrust, disgust with oneself, or self-destructive behavior. There may be strong encouragement or demands to hurt oneself or others.  

​

There may be unusual odors such as something burning, an odor of excrement/sewer gas, sulphur, or "poison gas."   There may be strange visual experiences -- seeing people, monsters, animals, or demons that will often speak cruel things like those listed above. There may be an unusual taste that leads individuals to believe there is something unusual in their food or they are being poisoned.

​

It may be helpful to note hallucinations are not the same as recollections of past experiences.  In this context, a hallucinated voice is not the same as hearing or remembering your mother's voice when you would do something in the past.  A visual hallucination is not the same as seeing or remembering something "in the mind's eye."  Hallucinations are new, unique sensory experiences that occur in real time. Most individuals will seek out the source of an hallucination for the first few times it occurs.    Also, the individual may ask others whether they also heard the voice or sound or saw something.  

 

​There may be frightening new beliefs that are not related to a person's five senses.  These are called delusions.  What is distinctive about delusions is that they are false beliefs but they are still believed to an absolute certainty by the delusional individual.  By definition, a delusion is a fixed, false belief that isn't part of a common cultural belief.  The falsehood is accepted with 100% certainty.   Once a belief becomes a delusion, the delusional person rarely, if ever, tolerates evidence or any discussion that contradicts the belief.  This occurs even if, on their face, the delusions are clearly and demonstrably impossible.   For example, a delusional male may believe he is pregnant with the devil's child without any acknowledgment or concern for the impossibility of his being or becoming pregnant.  

 

Common Depressive delusions include a belief one is damned irreversibly for having committed an "unforgivable" act (that may or may not have occurred); that the individual has a fatal, incurable disease despite a number of tests to disprove this; or there may a belief that the individual is already and irrefutably existing in hell.  

 

It is important to understand that these aren't metaphorical or clever statements to demonstrate a point.  We may dismiss or overlook these statements because they might be something  a "depressed," pessimistic person would say without necessarily believing them.  We may dismiss them also because they are often outrageous, and we assume the person is saying something for dramatic or ironic effect. For example, we may quip "I'm in hell" when asked how we are doing on a particularly busy day.  Unlike the delusional person, we do not mean it literally.  Very Depressed, delusional persons may say this and believe it without a doubt.  They will not modify the answer when given a chance to do so because they are certain it is true.  

​

Psychosis can be frightening and frustrating to the person trying to support the Depressed individual, but it is equally frightening to the individuals who have psychosis.  They struggle with terrifying experiences or beliefs that they cannot realize are false.   Furthermore, they are often afraid to discuss these experiences with family, friends, or their healthcare provider for fear they appear “crazy.”  

 

This is unfortunate because these experiences are fairly common symptoms of Depression.  They are caused by and are symptoms of the Depression itself.  Most people believe that only Schizophrenia generates psychosis.  In fact several diseases can generate psychosis.  For example, Depression, Mania, dementia, intoxication, and drug withdrawal are examples of other causes of psychosis.

​​

Conclusion

​In summary, Depressive symptoms can create great confusion, fear, and frustration for the person who is Depressed and for their loved ones who want desperately to help.  The good news is that Depression, once recognized, is a highly treatable disorder whose resolution can have profound effects to the betterment of the individual and those around them.