We use words like "depressed" and "depressing" to describe anything from a mild unhappiness to suicidal despair. Clearly mild unhappiness is not an illness and even suicidal despair may not indicate a medical problem if there's some adequate reason to despair. So what do we mean when we talk about "depression" or "clinical depression" as an illness?
DSM IV, the diagnostic manual used by the medical profession to classify mental illnesses, includes numerous categories and subcategories of depression. Some would argue that what is defined as depression has become so broad as to be almost meaningless.
Yet even in ancient times it was recognised that some people suffered from a particular form of mental illness, characterised by persistent and unexplained feelings of sadness, apathy, social withdrawal, poor appetite and sleeplessness. The Greek physician Hippocrates called it melancholia. Over the centuries the same group of signs and symptoms has been recognised as a distinct entity.
So let's come up with a definition of depression which would satisfy both the average GP and Hippocrates: depression is a condition characterised by persistent sadness or low mood, and a marked loss of interest in those things usually considered enjoyable, over most of the day, for most days, for at least two weeks. (Although it can be very similar, grief is not usually considered to be a form of depression, unless it persists beyond what is normal.)
About one in five Australians will experience at least one episode of depression during their lifetime. Many will have recurrent episodes. A much smaller number will suffer episodes both of depressive illness and mania, a condition called bipolar disorder. However, this article will consider only unipolar depressive illness.
The sadness which comes with depression is quite distinct from the normal "blues" . Some describe it as "feeling trapped inside a black cloud" or "being in a dark pit". Sometimes there's a sense of emptiness, hopelessness or loss of all feelings rather than sadness. Often the person's mood is lowest in the morning and picks up over the day.
People with depression feel apathetic and unable to perform many of their usual activities. They complain of feeling fatigued most of the time and lack enthusiasm, even for activities they once enjoyed. They may sit with their shoulders slumped, a sad and weary look on their face, (although many depressed people are able to hide how they feel). Some become incapacitated by anxiety.
The depressed person finds that their thinking is slow, difficult to control and prone to get stuck on ideas about how useless and worthless they are. Thoughts go round and round in circles until the person feels desperately weary of them. Concentration and memory are affected. Making even simple decisions becomes difficult. Feelings of guilt and self-loathing are unrelieved by talking about them or confessing them and ideas of death, or even suicide, sometimes occur. The depressed Christian may feel that God has rejected or abandoned them.
Along with the mental and emotional symptoms some people experience physical problems such as difficulty sleeping, poor appetite (or sometimes over-eating), constipation, and loss of interest in sex.
At a biological level, depression seems to be caused by an imbalance in the chemicals which help transmit messages from one neuron (brain cell) to another. There also seems to be a decrease in the number of connections between the neurons in certain parts of the brain, and even a loss of certain types of cells. This affects both the person's ability to think and the rest of their body's ability to function properly.
Several factors predispose a person to the these physiological changes. One major factor is heredity. Depression tends to be more common in some families. Even allowing for the possibility that children may learn depressive behaviour from depressed parents, there is still strong evidence of a genetic component (from studies of adopted children, for example).
Some people have a life-long pattern of thinking which seems to set them up for becoming depressed. For instance, they might think in black and white terms - "If I'm not a complete success, then I must be a failure". They may catastrophize - "If this or that happens, then my whole world will collapse". They may tend to notice and remember the worst rather than the best aspects of what happens to them. Whether this way of thinking is learned or already "wired into" the brain of those who are predisposed to depression is still being studied.
One widely-held belief, first put forward by Sigmund Freud, is that depression is a result of "in-turned anger". Despite its popularity, there is no good evidence for this theory. However, there is evidence to support the idea that depression is associated with loss of some kind. A significant proportion of those who suffer from depression have experienced some significant loss in early childhood. A loss in later life, even if it is relatively minor or intangible, then seems to trigger a response that leads on to depression.
Finally, a number of illnesses can either mimic depression or trigger it. These include anaemia, hypothyroidism, and viruses such as glandular fever. The hormonal changes associated with pregnancy, the post-natal period and menopause are also associated with a higher incidence of depression. Some medications, and some drugs such as alcohol, can produce depressive symptoms.
Untreated, depression can last from a few weeks to several years, with the norm being about twelve months. The disruption this causes to a person's relationships, work, and lifestyle can be profound. Until the last century, those who suffered depression simply had to endure it, unless they chose to bring it to a drastic end in suicide.
The introduction of antidepressant medications changed the course of the disease for most sufferers. While the overuse and misuse of such medications has come in for some warranted criticism, it's hard to overestimate the relief that they have provided to people whose pain is mostly hidden but very real.
There are a number of different types of antidepressant tablets, and what works for one person may not work for another. About 80% of people respond to antidepressant medications, but sometimes more than one needs to be tried. It usually takes a week or two for their antidepressant effect to be felt. Antidepressants are used for all types of depression, but seem particularly effective in those who have associated physical symptoms such as insomnia.
Adequate exercise, rest and nutrition are important in getting better and staying better. Some studies have shown that regular exercise, such as walking daily, can be as beneficial as medication in mild to moderately severe depression. Tests to rule out other illnesses such as anaemia are also important.
Some form of counselling is often helpful, and may even be enough by itself where the depression is not severe and there are few physical symptoms. In general, counselling which helps the depressed person learn how to change and control their thinking pattern and develop problem-solving skills is at least as helpful as in-depth analysis and "talking therapy". Learning new thinking and problem-solving skills is also helpful in lowering the risk of further episodes of depression.
Recent research using brain scans has found that directed counselling such as cognitive behavioural therapy actually produces the same changes in the cellular structure of the brain as antidepressant medication. However, no counselling is effective unless the person undertaking it is motivated to keep practising what they learn.
Where there are real problems with a marriage, work situation or other relationship, (not brought on by the depression itself) these need to be tackled. It's often difficult to know which is the chicken and which is the egg - problems that seemed overwhelming and a cause for being depressed can look quite insignificant when normality is restored. Expert help is often required in these situations.
The person who is depressed is often very poorly motivated to do anything about it. They feel too helpless and apathetic, too convinced that they deserve what they are going through, or too certain that everything is hopeless. Those who have to live with the sufferer often begin to suffer themselves. For these reasons, if you know someone who seems depressed, it's important to encourage them to seek help. If you think you might be depressed yourself, talk to someone about it, visit a GP, learn more about depression. Any positive action is the first step towards getting better.
What about prayer and other types of Christian ministry? Can't depression sometimes be a spiritual problem? So far I've looked at depression from a medical point of view, but obviously there are spiritual aspects to all types of illness. In a second article I'll look at how we might understand depression from a Christian perspective.
Stella Budrikis