Depression overview: Understanding and treating depression

It is estimated that about 20 per cent of us become clinically depressed at some point in our lives. Whereas sadness and grief are focused entirely around an experience of loss, depression refers to an experience where a person becomes convinced there is something seriously wrong with them.

When someone feels sad, it is generally a normal and healthy response to some misfortune they have experienced. Most of the time, their mood is a reaction to the loss of a person, a social role, a close companion or a place to which they felt attached. Generally, they will share their grief with someone and be open to receiving whatever support they get as they come to terms with their loss.

If sadness is a natural response to loss, depression is a very painful experience of believing oneself to be a “loser”. In depression, a person’s distress may have been triggered by some loss in their life, but their attention very quickly shifts away from whatever they have lost to a preoccupation with a personal sense of failure, inadequacy and helplessness. Each loss is interpreted as further proof they are incompetent or unlovable. Lacking any belief they are worthwhile, they may turn away from others and become withdrawn and unresponsive to offers of help.

When someone becomes depressed, it is not simply that they feel down. Their capacity to think clearly and make decisions is diminished, their physical health suffers, and the energy they normally have to deal with life drains away. A person who becomes depressed also experiences a complete lack of satisfaction from the activities, relationships and pastimes that had always given their lives a sense of meaning and joy.

It is estimated that about 20 per cent of us become clinically depressed at some point in our lives. This figure seems to have stayed the same over the past 50 years.

The most frequent ages for people to experience depression for the first time is between 13 and 15 years' old. This is a disturbing statistic because it suggests that young people experience depression at a time in life when they are least able to cope with it. Suicidal thoughts and self-harm attempts are very common in about two-thirds of young people who feel depressed. Studies have reported actual suicide attempts in 6 to 12 per cent of depressed children and young adolescents. These rates appear to be higher among young people than among depressed adults.

When you consider that people are experiencing depression earlier and earlier in their lives, and that it recurs in more than half of those who experience it, then it is clear there are far more people suffering from depression on any given day than one might realise.

CAUSES, SIGNS AND SYMPTOMS

Depression is characterised by a particular set of changes in how a person thinks, feels and behaves.

Changes in thinking: the past, the present and the future are all viewed though a dark lens that distorts everything. Important achievements in the past don't count. She or he focuses exclusively on every sign of failure or weakness that they can possibly point to in their life. They see the future as a relentless continuation of their current misery, where nothing good will ever happen for them. These preoccupations make it hard to concentrate on anything or to believe there is any good in themselves. Making a decision can be an enormous strain because they don't trust themselves to do the right thing.

Changes in feeling: if you have never been depressed, it is hard to appreciate just how intensely painful depression can feel. People who are depressed often find it very hard to put their feelings into words. They also fear that if they were to say how badly they were feeling, other people may be shocked and write them off as insane.

Depression is, for many people a very physical experience and the symptoms they describe are often to do with changes in their body. They may describe the sensation of hurting deeply inside or they may have physical symptoms which worry them, but which have no apparent physical cause. Sleep disturbance is probably the most common physical symptom of depression. Sufferers usually report a broken sleep pattern that results in waking without the sense of being rested or refreshed. Their normal appetite may also be affected, resulting in either excessive eating and weight-gain, or a complete lack of interest in food, which leads to weight-loss. They may also find themselves unable to make love and indeed have very little interest in doing so, and this can be a major worry for them.

Changes in behaviour:

It is not always easy to recognise that someone may be depressed. No matter how intensely distressed they may feel inside, many people hide it very well on the outside. And even when someone behaves out of character, we may not realise they are depressed, and mistake their behaviour for something else. A significant slowing down in activity is a very common feature of depression, although some sufferers can become restless, even hyperactive, as they try to block out the turmoil they experience inside. Excessive busyness can be a protective mechanism to distract from this turmoil, but it leaves a person feeling constantly on edge and hypersensitive. The most common behaviour that reflects depression is a lack of energy and social withdrawal. A tendency to take to the bed is all too common. Sometimes, it can seem easier just to retreat from the world to avoid having to deal with the criticism, demands, even concerns, of loved ones and friends.

Depression may be experienced to a mild, moderate or severe degree. In its mild or moderate forms, it is characterised by negative thinking and low self-esteem, irritability, and difficulty in concentrating. In the more severe forms of depression, the same symptoms are experienced with greater intensity and physical manifestations of this distress are more apparent. Symptoms of fatigue, insomnia or hypersomnia (too little or too much sleep), decreased or increased appetite, significant change in weight, and a marked slowing down of physical and mental activity indicate the need for professional help. Suicidal thoughts often lurk just beneath the surface and should always be checked for and regarded with the utmost seriousness.

Checking your mood

The list below identifies the 12 most common signs of depression. To help you clarify what your experience of depression may or may not be, read each one and write ‘Yes’ beside any that describe how you have been feeling, for most of the time, over the past two weeks (or longer).

1. I have been feeling down most of the time.

2. I get no pleasure from the things that normally mean a lot to me.

3. I feel tired all the time.

4. I can't concentrate and remember details.

5. I have lost weight quite dramatically.

6. My sleep is disturbed and doesn't leave me feeling rested.

7. I am more irritable than usual.

8. I have lost all confidence in my ability to make decisions.

9. My thoughts are mostly self-critical and gloomy.

10. I feel guilty without really knowing why.

11. I feel sensations in my body that trouble me.

12. I have thoughts of killing myself.

If you have answered ‘Yes’ to either of the first two items and ‘Yes’ to four or more of the remaining items, you may be experiencing depression. The higher the number of items to which you answered ‘Yes’, the more severe may be your depression.

PREVENTION AND TREATMENT

The most striking characteristic of people who are prone to depression is their belief there is something fundamentally bad or unlovable about them as human beings.

We know that people who have experienced trauma in their early life (defined as an emotionally overwhelming experience of neglect, abuse or loss) are more vulnerable than most to low self-esteem and depression.

When we are children, we are immensely fragile and utterly dependent on the care and protection of others. When we are loved and offered warmth in a consistent way, we feel secure and our whole body expresses gratitude and affection. But our dependence on others also leaves us vulnerable. If our parents or carers are not able to be there for us, or if they are abusive or shaming, we become distressed. Because we are children, we may imagine their behaviour must have something to do with who we are, or that there is something we are doing that makes them behave in the way they do. By the time the mind has been able to comprehend what may have happened, the wounds of the heart are already too deep.

Sometimes it is not what happened in a person’s early life, but rather what is happening in their lives right now that leaves them vulnerable to depression. Poor housing, social isolation and the pressures of rearing young children with no support may be what causes or contributes to a person’s depression. One important piece of research, which highlights the crucial role of social support in staying mentally well, is the finding that women in stressful social circumstances with even one close, confiding friend were four times less likely to become depressed than women in similar circumstances who did not have such a friendship.

Unemployment can undermine a person’s self-confidence and where there is any vulnerability to depression, it may aggravate it. Research has found that people are 10 times more likely to be depressed if they are unemployed; in other words, being employed decreases one’s chance of becoming depressed by a factor of 10.

Whenever we talk about depression, there is a danger of thinking about it exclusively in terms of psychological experiences that cause us hurt. We can forget we are physical beings with bodies that have a significant impact on how we feel. Some people carry in their bodies a tendency to become depressed, simply because of the constitution they have inherited.

Depression is a very physical experience. Taking care of our bodies is critical to recovery. Medication can be very important for some people, particularly when they are severely depressed or when they have a known vulnerability to bipolar disorder. Exercise and the right kind of nourishment are also critical to both our physical and psychological wellbeing. When we deprive our bodies of these needs, we aggravate the experience of depression. Recovery involves listening to what our bodies need and doing right by them.

Recovery from depression begins with the courage to acknowledge that we are in a difficult place and that we owe it to ourselves to do something about it. We need to let go an insistence that we be perfect and work at being kind towards who we actually are. Kindness to self is the most powerful anti-depressant and it’s the hardest thing to do when we’re feeling down. We are so full of ‘shoulds’. We need to keep checking in with ourselves and ask what is manageable for me right now? “What would help me to feel calm right now?” Here are some things that have been found to be critical in recovery from depression:

Do one thing

One of the most consistent findings in the studies on depression is that activity helps our moods. Because you may not feel like doing anything when you are depressed, it is a good idea to think about one or two things you would like to get done each day and plan how and when you’re going to do them. Writing down these activities in a daily diary first thing in the morning (or the night before), focuses your mind on the day ahead. This way, you are able to consider doing something that might help your mood, rather than allowing your mood to drag you deeper and deeper into a black hole. Doing one thing, one thing at a time, no matter how small, no matter how simple, can restore the feeling that I’m not completely helpless, that I can take control of my life. Self-confidence grows with each small success and gradually leads to a person approaching tasks that they have been too frightened to take on.

Activation precedes motivation

Research has shown that when we are depressed, we react to our distress in the following way: we focus our attention on how we are feeling rather than on what we could do to ease our pain. We tell ourselves that, “If I don’t feel I can do it, it probably means I shouldn’t even try”. We procrastinate and convince ourselves that, “I’ll do it later, when I feel more like doing it”.

The problem with this way of thinking is that it assumes the feeling or motivation for doing something should come before you actually do anything. In fact, the opposite is true when you are depressed. Activation precedes motivation. When you feel low, the motivation to do anything comes after you’ve started into the task. If you set about doing something that you’ve been avoiding and take even very small steps towards achieving your goal, you will be surprised at how the energy for that task comes in the doing of it.

Don’t go it alone

Hopelessness thrives when we lose our connection with the world around us. We may feel angry and hurt that life has turned out the way it has and that we have failed in some way. This anger and hurt can turn into bitterness and a stubborn refusal to have anything to do with life.

To overcome depression, you need to move out of isolation and experience genuine contact and nurturing from other people. You won’t resolve your depression by trying to figure it out all alone inside your head. Solitude is important at times – it can give you a welcome break and enable you to get some perspective on the problems in your life – but, when you’re depressed, solitude can magnify your negative thinking, so that you end up going round and round inside your head without resolving anything.

Turn your inner conflicts into conversations

Recovery from depression involves becoming open to what is troubling you at an emotional level. Painful feelings and associated painful memories often require a safe setting within which you can confide in another person and gain the support you need to talk through what has been avoided for so long. Unwanted feelings and memories are often avoided because people feel they will be too much to bear. The support of a counsellor or friend can enable you to face your fears gradually.

A good listener is someone with whom you feel safe enough to speak, and with whom you can gradually find the words to say what you are feeling. Being able to put your feelings into words enables you to get some distance from how you are feeling and to see more clearly what is happening. When you keep everything bottled up inside, you can’t see the wood for the trees and can feel so overwhelmed by all that is happening inside you that you resort to destructive ways to block out and numb your feelings.

Pay attention to even very tiny breakthroughs

When you feel depressed, you see your whole life through a dark lens. It is more than likely you filter out everything good that ever happened to you, and remember only those experiences that fit with the painful way you feel in the present. You may not see this ‘memory bias’ at work, because it happens automatically, without you ever noticing. Writing can be a way to correct this bias and to acknowledge small but significant breakthroughs.

At the end of each day, see if you can recall an event that lifted your spirits. Record these experiences in your journal. Being thankful for moments like these can ease the pain of depression and restore a larger perspective on your life.

USEFUL RESOURCES

Some recommended reading on depression

Coming Through Depression, by Tony Bates
This book details what depression feels like for those who experience it and offers clear steps to help people through it. It is an empowering book, making it clear that depression need never have power over us because we ourselves have the power in our own lives. It is written in a language that speaks clearly and directly to the reader. It acknowledges that while people can lose their way, they can also find it again. It introduces mindfulness and the role it can play in the acceptance and recovery from depression.

Beyond Prozac: Healing Mental Distress (2004), Terry Lynch, PCCS 2nd Edition
A very readable, thought-provoking and hard-hitting book. Terry Lynch, the author, a medical doctor with 18 years' experience, is convinced doctors prescribe tranquillisers and anti-depressants far too easily.

Sunbathing in the rain: A Cheerful Book About Depression, by Gwyneth Lewis, Flamingo, 2002
Sunbathing In The Rain is such a lovely title for a book about beating depression. Gentle and elliptical, it still tells us everything we need to know. Lewis takes us through the few highs and many lows of a depression that left her dead to the world in her late 30s. She examines the triggers for the depression – alarm bells ringing on the hormonal clock; struggling with two careers as a BBC administrator and poet; a crisis of confidence in her poetry. She tells us she is genetically susceptible – her mother's depression threw a silent curse over her childhood.

Depression: The Way Out Of Your Prison, by Dorothy Rowe, Routledge 1996 2nd edition An easily understandable, comforting type of help for depression sufferers. The author may have feared some readers would come to view depression as a purely chemical problem, and therefore beyond one's own control. Depression described as a biochemical imbalance would also suggest chemical solutions, which the author personally dislikes.

Overcoming Depression, by Paul Gilbert This book clarifies and simplifies what is for most people a dark, scary, overwhelming mystery. It helps us to see depression for what it is. People are not randomly and unfortunately afflicted with a strange disease they're powerless to affect. All people have the potential to enter a depressed state, and similarly all people have the potential to live in a state of vitality/normality (whatever the opposite of depression is).

Mental health support organisations and websites in Ireland

Aware: www.aware.ie
Aware is a national voluntary organisation that aims to support people who are experiencing depression. Its website contains information and tips on coping with depression. It also contains details of support groups and services for people with depression.

Bodywhys: www.bodywhys.ie
National voluntary organisation Bodywhys aims to support individuals and their families in relation to eating disorders. Its website has information and links to services and supports, including details of a lo-call helpline.

Grow: www.grow.ie
Grow is a voluntary mental health organisation that aims to support people who have suffered, or are suffering, from mental health problems. Its website provides information on Grow.

Headstrong: www.headstrong.ie This is a national organisation committed to changing how Ireland thinks about young people and their mental health, and to establishing youth-friendly accessible supports for all young people in their local communities, called Jigsaw. Specific information regarding Jigsaw services can be accessed via www.jigsaw.ie

Headspace Toolkit: www.headspaceireland.ie
A Mental Health Commission website with information and downloads for young people who are inpatients in mental health facilities. It aims to supporting young people in being included in decisions that affect them and ensure their rights are upheld. Downloads include resource packs with information for young people to use.

Let Someone Know: www.letsomeoneknow.ie
A Health Service Executive website aimed at promoting mental health and help-seeking in young people. It includes tips for young people on how to look after their mental health.

Mental health Ireland: www.mentalhealthireland.ie
Mental Health Ireland is a national voluntary organisation with 104 local mental health associations (MHAs) and branches throughout the country. MHI aims to promote positive mental health and to actively support people with mental health difficulties, their families and carers by identifying their needs and advocating their rights.

OCD Ireland: www.ocdireland.org 
The website of OCD (obsessive compulsive disorder) Ireland, with information and links for people with the condition and other related difficulties.

Pieta House: Centre for the Prevention of Suicide or Self-harm: www.pieta.ie
Pieta House is a support and counselling service for people who self-harm or feel suicidal.

Reachout.com: www.reachout.com
Online mental health resource that provides high-quality mental health fact sheets and a detailed overview of the range of informal and formal mental health supports available in Ireland. ReachOut.com also engages young people by publishing personal stories about getting through tough times and finding the support and inspiration to face up to and overcome mental health difficulties

Samaritans: www.samaritans.org
The Samaritans is an organisation that provides confidential non-judgmental emotional support, 24 hours a day for people, who are experiencing feelings of distress or despair, including those which could lead to suicide.

Shine: www.shine.ie
Shine is a national voluntary organisation that supports people, and their families, who are experiencing long-term mental health difficulties. There is information on the site about the support services offered by Shine as well as an information helpline number.

Your Mental Health: www.yourmentalhealth.ie
A Health Service Executive website that provides information on looking after your mental health

1Life: www.1life.ie
1Life provides a 24-hour suicide-prevention and intervention helpline providing professional counselling services for anyone who has an issue related to suicide, whether an individual in suicidal crisis or a person seeking advice or information on behalf of another. 1Life provides a freephone telephone counselling service as well as text and cyber counselling.

Dr Tony Bates is a clinical psychologist