How can we understand depression? It is important that we distinguish between feeling depressed and having a depressive illness/depression.
Feeling “depressed” can be an everyday feeling and may include such states as anxiety, happiness, sadness, anger and very often depends on our circumstances. Depressive feelings tend to set in when something happens that leaves us feeling out of control to the extent that we might only be able to restore a sense of control without a great deal of effort.
To understand depression it might be useful to visualise it in graph form as shown here. The top bar shows a rhythm associated with psychological well-being whereas the bottom bar represents that of a person who suffers a depressive episode or illness. The midline could be the boundary between psychological wellness and depression.
Psychological wellbeing means that you might find yourself sometimes above (content or even slightly elated) or below (feeling a bit depressed or low) the top bar. These should be seen as normal fluctuations within healthy people. When you find yourself in the top section and you experience low mood it could be relatively easy to motivate yourself and reinstate a sense of contentment. The typical saying ’I need to pick myself up’ normally has a positive effect if applied. The closer you dip to the midline the more difficult it becomes to pick yourself up again.
If you find yourself consistently below the midline, a depressive illness could be a real possibility and needs to be addressed accordingly. When there is a drop in mood below the midline all experiences and perceptions become the opposite to experiences above this line. Where it is possible to cognitively and behaviourally pull yourself up when above the midline it now becomes more difficult as it confirms your inability to restore your emotional balance (this is due to a chemical imbalance and psychological pressure). Not being able to restore emotions may give rise to negative thoughts, which can drag the person down into a state of negativity and nearer to that critical point where a depressive state is entered. Common thoughts such as ‘I am not good enough’ or ‘I am not strong enough’ become more frequent; however, the necessary energy is not present to break the onset of a negative cycle. A person might be quite good at putting up a pretence in public but they may find it difficult to keep it together when they are on their own or in a safe place such as their home or with a trusted person. (refer section on symptoms of depression).
Reasons for depression – biochemical or psychological?
We have to acknowledge that all activities and thoughts involve a biochemical process within the brain. Our emotions or moods are effected by serotonin (the chemical that carries messages up and down the brain). With depression an imbalance of the serotonin levels affect the way the receptors in the brain receive and send information. When the serotonin levels are low due to it not being taken on or not released from the neurotransmitter it causes a delay in our brain functioning. This in turn has an effect on our behaviour and cognitions.
The two most common-described types of depression are Endogenous Depression and Reactive Depression. Endogenous depression is believed to be passed on through a larger genetic component than social and developmental factors. Reactive depression is seen to be more due to stressful life events and development factors.
As much as there are physiological effects present in depression there is almost certainly always a psychological component to it as well. The psychological effect can be twofold: it could be the reason or cause of the depression or, if the depression is more endogenous, psychological factors would have a secondary effect of the depression (inducing negative beliefs and thoughts).
What type of therapy helps for depression?
When a depressive illness has been identified most medical doctors talk of a bio-chemical imbalance (as described above) and you may therefore ask yourself whether you need to take anti-depressants or whether a psychological approach might be more beneficial. The answer here depends on the severity of the depressive illness. A depressive illness should be seen on a continuum from mild to severe. Normally in mild cases of depression counselling or self-help information should be adequate. People with a moderate depression tend to respond well to more advanced therapeutic (i.e. psychological) approaches. It should be noted though that in cases where there is a moderate to severe depressive illness anti-depressants combined with psychological therapy has proven to be more effective. In some cases medication alone might be enough to get people to work through the depressive illness with the necessary support from family or friends.
The use of psychological approaches could have two possible effects: Where the underlying cause of the depression is suspected to be psychological in nature, therapy may focus on the reasons or causes of the depression and will be aimed at helping the individual to identify negative thoughts and beliefs that have established themselves, which serves to maintain the depression. Once this is identified therapy would then focus on helping the person to change these negative thoughts and behaviours and to facilitate the integration or resolution of suppressed or blocked emotions. If the depression is more of an endogenous nature, and therefore more genetically predisposed, the psychological therapy deals with the secondary psychological effects that would have led to negative thinking and behaviours that are associated with depression. With an endogenous depression, psychological therapy would not look at resolving the depression but focus on more helpful strategies to maintain stability
How do I recognise a depressive illness?
The first question to ask is how does my negative mood effect my day to day activities? When someone is depressed they may find it difficult to acknowledge it to themselves because they may feel that they have failed or given in to the illness. People with depression often describe feeling trapped in a dark well or stuck in a black tunnel. To diagnose a depressive illness most of the following symptoms should be present for two week or more.
A depressed person may feel that they are emotionally up and down and get quickly irritable when things are rushed or there is too much activity (even something small like children running around or playing) or they may be startled by the phone or doorbell ringing. Depressed people typically find it difficult to feel motivated enough to do things, even simple tasks, because they feel emotionally so low and lack physical energy. There is a loss of interest or pleasure. They find it difficult to concentrate and are often bombarded with thoughts that are negative, such as ‘How am I going to get through this‘ or ‘I don’t deserve anything, I am not good enough’. Suicidal thoughts or thoughts relating to the need to escape the feelings will be present.
Another very common symptom associated with being depressed is the need to withdraw – the need for isolation (to be alone) as well as a withdrawal into a wash of inner thinking. An example here would be the person who sits and stares at the television. In reality, whilst sitting, random irrational and negative thoughts are triggered by what the person sees or hears.
Depressed people often complain about the lack of concentration which causes a lapse in short-term memory, forgetfulness (mislaying keys, forgetting what you wanted to do moments later). Long-term memory seems more intact depending on the severity of the depression. Any structured problem-solving thinking becomes an effort when depressed with indecisiveness being present.
Sleep is affected and depressed people may experience difficulty falling asleep despite feeling dead tired because their thoughts are racing as soon as they hit the pillow which prevents them from falling asleep. Others have difficulty waking up, remain tired even if they have slept well and still manage to sleep most of the day. The sleep pattern is normally associated with broken sleep. It is quite common for people with depression to fall asleep only to wake up in the dead of night. Irrespective of how much they sleep it seldom feels enough, their energy levels never feel as if they are being restored, and this leaves them feeling tired and worn out.
Appetite or eating is affected by the person either not eating (finding it difficult to face food) or over-eating (feeling that they need more or cannot have enough). This is also commonly known as comfort eating and is normally associated with significant weight gain or loss.
As mentioned before there is a lack of energy and motivation and although the depressed person has good intentions to do things, when it comes to doing them it becomes too much and often leads to postponement which in turn triggers the confirmation of negative thought such as ‘I am not good enough’ which erodes confidence and fuels depression.
A low libido or sex drive is also associated with depression.
It is important to note that depression in childhood can be associated with an irritable mood.
What makes it sometimes difficult for some people to take up therapy is that they just see the process of talking as too tiring because they already feel so worn out or exhausted. Some even feel they would be giving in to the depression which they fear may prove that they have failed. For others it is the fear of talking or revealing private aspects of themselves which make them feel very uncomfortable.
As mentioned earlier, psychological therapy aims to look at the possible underlying causes and helps the person to identify negative beliefs and thoughts that effects their mood. In cases of mild depression this might be enough to break the depressive cycle. In cases of moderate to severe depression on the other hand, where negative beliefs and thoughts are too ingrained, the therapeutic process is aimed at gaining an understanding of the psychological processes (dynamics) that are keeping the person trapped in a negative cycle. As previously mentioned, it is also geared towards an understanding of the possible origins of the problem. For some a possible cause could be a traumatic event or a catalogue of events over time. In these cases a psychological formulation, which is an essential part of an intervention, often proves to be most helpful to both therapist and client. Therapists will take into account the person’s history, personality type (ways of thinking), and various events that have shaped the way he/she thinks and beliefs that have developed over time. Contextualising these aspects aids understanding and helps to integrate emotions.
Choosing psychological therapy or a therapist can be difficult as there are many people providing therapies of all kinds. Within the NHS, Cognitive Behavioural Therapy (CBT) is mostly provided, which focuses on the here and now, using beliefs and thought processes in dealing with the problem. Private psychological therapy varies more with psychologists, psychotherapists and counsellors providing a wide range of therapies and approaches. It is advisable to choose a therapist who is registered with a professional body as they would be accountable for what they provide. It would also mean they would have had accredited training. Depression and any other mental health difficulty being of a moderate to severe nature has no quick fix. The length of therapy depends on the severity of the depression and type of therapy itself. A psychologist and psychotherapist should be able to give a good indication of the relative length of therapy after a full assessment.
More information on depression: