Winter 2009

Society and Culture

Depression

Brian Orchard

Experts tell us that today most depression can be cured. Can it also be prevented?

It may manifest itself, especially at this time of year, as the “post-holiday blues.” Or, as winter drags on in northern climes, it may set in as “seasonal affective disorder.” In new mothers, it might be labeled a severe case of the “baby blues.” For many, however, depression has no direct tie to seasons or events. It’s just a fact of life. 

 One of the leading causes of disability today, according to the World Health Organization, is depression. So the chances are that, no matter where you live, you either know someone who is struggling with depressive illness or have dealt with it yourself. In America, up to 20 percent of the population is likely to suffer depressive symptoms at some point in their lives, and 5 to 10 percent are diagnosed as having major depressive disorder in any year.

Further, those who diagnose and treat this growing problem report that they are seeing it at a younger age in successive generations. The U.S. government’s National Mental Health Information Center indicates that at any point in time, up to 15 percent of children and adolescents show some symptoms of depression.

Still, researchers say, the problem is underdiagnosed and undertreated. Many sufferers may not even consider that they are depressed, instead seeking help for physical symptoms such as sleeplessness, aches and pains, or lack of energy. Numbers can also be skewed by the fact that men are less likely than women to seek help, perhaps because of societal stigma or embarrassment.

Statistics abound, but however the numbers are interpreted, the consensus is that the incidence of depression is growing; it is happening earlier in life; and it is of major concern to health-care professionals. On the positive side, as medical researchers come to understand the problem better, they are developing new approaches to treatment—approaches that go far beyond improved medication and instead emphasize changes in personal behavior.

Recovery from depression is like recovery from heart disease or alcoholism. The good heart patient knows that medication isn’t enough; lifelong habits of diet and exercise, how one deals with stress, must change.” 

Richard O’Connor, Undoing Depression

Based on some of these findings, what can individuals and families do to stem the tide of depression and perhaps help future generations avoid this mentally crippling illness?

Defining the Problem

Depression is a mood disorder and should not be confused with the ups and downs that are a part of normal life. Clinical depression is characterized by extended periods of feeling sad or empty, where nothing is enjoyable and physical activity declines. Symptoms include mood swings, feeling numb, changes in eating and sleeping patterns, a lack of energy, and a sense of worthlessness or inadequacy. In the case of chronic mild depression (dysthymia), a person can function but not to full capacity, which often allows the problem to go unrecognized.

Emotions clearly play a part in the problem, yet they are a normal part of life as mind and body react to situations. These feelings are mostly transient in nature; they come and go throughout the day. However, when emotions become intense and unremitting and are not tied to a particular stimulus, they are called moods, and extreme and persistent moods can lead to depression.

Another factor in depressive illness is stress—a key feature of modern life. Again, however, not all stress is harmful. Like emotions, it can be good or bad, depending on its length and severity. A short period of stress enables us to accomplish tasks and to treat problems as challenges. This is referred to as good or acute stress. The bad stress is chronic and can have negative physical effects on the body, including insomnia, sickness and depression.

Who Gets Depressed

Certain sections of society are more at risk for depression. By some estimates, women are twice as likely to become depressed as men: boys and girls have the same level of risk until age 12, after which the risk for girls doubles through adolescence and remains consistently higher until after menopause.

A U.S. government agency, the National Institute of Mental Health (NIMH), reports that “biological, life cycle, hormonal and psychosocial factors unique to women may be linked to women’s higher depression rate. Researchers have shown that hormones directly affect brain chemistry that controls emotions and mood.” The article goes on to point out that “women are particularly vulnerable to depression after giving birth, when hormonal and physical changes, along with the new responsibility of caring for a newborn, can be overwhelming.” While this may result in nothing more than a brief episode of the so-called baby blues, it may also turn into a more serious condition known as postpartum depression. Hormonal changes in women around the time of menopause may also be linked to an increased risk for depression. 

Further, the NIMH notes, “many women face the additional stresses of work and home responsibilities, caring for children and aging parents, abuse, poverty, and relationship strains.” It is worth noting, however, that not all women faced with such difficulties become overwhelmed by them. According to NIMH, “it remains unclear why some women faced with enormous challenges develop depression, while others with similar challenges do not.” 

Depression also tends to run in families, with the genetic risk again being more pronounced in women than in men. Another factor is negative early childhood experiences, including the loss of a parent before age 10, physical or sexual abuse, or some other traumatic experience that acts as a trigger later on. 

A final causative factor is major life events such as divorce, assault, loss of job, chronic stress, serious illness, or bereavement. In the case of the latter, grief over the loss of someone close is a normal emotional reaction and will not automatically lead to depression if it is worked through, though this may take many months. Grief can lead to depression, however, if it is allowed to sink deeper over an extended period. 

Predispositions notwithstanding, there is no certain way to predict who will become depressed. Difficulties in childhood or a major disaster in later life can lead to low self-esteem, a sense of rejection, and an inability to feel good about oneself or one’s life. Yet some people who have no such histories, who appear stable and well integrated, can nevertheless fall into a depressed state. Likewise, people who have suffered a childhood trauma or who are subject to significant stresses or life changes are not unavoidably doomed to a life of depression. 

Diagnosis and Treatment

The good news is that most depression is treatable. As with other health issues, of course, the sooner treatment is sought, the better the chances of success. If left untreated, the risk of successive episodes increases dramatically. And as risk increases, so does the probability of related problems such as drug addiction, alcohol abuse and suicide. (See “Depression and Suicide.”)   

So what should you do if you suspect that you or someone close to you is displaying symptoms of depression? The first course of action is to establish whether the symptoms have developed from a mood disorder or from a physical cause. Many symptoms can be the result of factors such as thyroid malfunction, vitamin deficiency, sleep apnea, medications or hormonal changes. Fatigue and tiredness from stress can produce depression-like symptoms as well.

This means that diagnosis is not as straightforward as one might expect, and it helps explain the already noted problems of underdiagnosis and undertreatment. According to a study published in the Primary Care Companion to the Journal of Clinical Psychiatry, “only 50 percent of patients with depression who are seen in the primary care setting will be accurately diagnosed, and, of these, less than 10 percent will be appropriately treated” (“Depression: Diagnosis and Management for the Primary Care Physician,” October 2000).

Treatment options are also increasingly varied as professionals move beyond the belief that simply prescribing an antidepressant is appropriate treatment for someone suspected of being depressed. Specialists now approach treatment from a variety of angles, and as each person is different, so is the application of treatment. Some depression may need a drug or a combination of drugs to assist in recovery, while some can be treated without medication. It is important to keep in mind that there is no valid way for a practitioner to know which treatment will help an individual patient. The individual and his or her family need to take very personal responsibility and ownership of the problem and actively pursue successful solutions. This is why therapy can be a particularly helpful part of the healing process: it keeps the patient focused on working with the problem. Most depression is treatable and curable, but getting help and keeping up the fight are key.

Mind-Bending Science

Research on the brain has revealed that brain function is an important factor in both the cause and the treatment of depressive illnesses. Neuroscience continues to unlock knowledge of how the brain operates and is leading researchers to astonishing new insights into how we think—a key element in depression.

Some say there are more than 100 billion neurons, or brain cells, in the human brain. Each is connected to thousands of other neurons, and each can fire electrical and neurochemical messages hundreds of times a second to other neurons across synapses. Neurons either conduct an electrical charge or don’t conduct it. Chains and circuits of these “on” and “off” neurons underlie all our mental processes. They create neural pathways that elicit responses of movement, perception, sensation, language and thinking. The more frequently these pathways are traveled, the more entrenched—that is, habitual—a resulting behavior or perception or thought becomes.

All of this neural communication takes place with the help of chemicals called neurotransmitters. There are known to be more than 30 different neurotransmitters in the brain (some estimate 100 or more). A few of them, called monoamines (including serotonin, epinephrine and dopamine) are known to contribute to mood stability, although abnormal levels can result in persistent mood disorders.

In the 1960s it became popular to ascribe depression to exactly such chemical imbalances in the brain. The “monoamine hypothesis” focused on a deficit of serotonin in particular as the cause of depression, and treatment became drug-oriented as a result.

However, by the late 1990s emerging research showed that antidepressants, by increasing serotonin levels, actually encourage the growth of brain cells in the hippocampus, a part of the brain associated with mood regulation. The revelation that the adult brain is capable of producing new neurons has not only revolutionized the treatment of depression but has led to the far-reaching conclusion that the brain can develop new neural pathways by changing the way it thinks. When we respond to trauma and other major life experiences in childhood, we create a neural pathway in the brain. When similar events occur later, they trigger a response that defaults to that already existing pathway. Thus, if our earlier response was negative, then the brain is likely to respond to the later event with negative thoughts and a correspondingly low mood. Over time, it becomes habitual for the brain to react negatively to the familiar triggers. The task is to break the cycle.

The result of this breakthrough in brain research is that instead of trying to explain and treat depression from a single point of reference, doctors now typically approach it with a combination of treatments. Medications are no longer necessarily the first line of attack. They can be useful, particularly in more serious mood disorders, but techniques that help the depressed person change the way he or she thinks can assist the brain in forming new cells and alternate neural pathways. This not only aids in recovery but has obvious implications for the prevention of relapses.

Lifestyle Choices

A brain that is damaged by early-life trauma, chronic stress or even genetics has the power to heal that damage. The brain changes according to experience, or as neuroscience is telling us, it can be “rewired” to think in new ways. (See “Rewiring the Brain.”) 

As noted earlier, much of the current research indicates that depression is increasing from one generation to another and is being diagnosed at a younger age on average. Although genetics play a role, this trend also suggests a link between depression and lifestyle.

In regard to a person’s longevity, genetic factors are said to be 30 percent responsible, while lifestyle factors account for 70 percent. In other words, longevity is not only in the genes, it is also a result of the lifestyle choices we make.

Similarly, the connection between lifestyle and disease is undisputed. The Centers for Disease Control state that “chronic diseases account for 70 percent of all deaths in the U.S. . . . Although chronic diseases are among the most common and costly health problems, they are also among the most preventable. Adopting healthy behaviors such as eating nutritious foods, being physically active, and avoiding tobacco use can prevent or control the devastating effects of these diseases.”

What has not been so obvious up to now is the connection between lifestyle and depression, at least in terms of treatment. After all, what is lifestyle but a way of life, a set of behaviors?

Psychotherapist Richard O’Connor puts it very directly: “I believe that people can make substantial changes in how they live their emotional lives, in their personalities, even in their brain chemistry, by making changes in their behavior.”

Research has shown that positive emotions and interventions can bolster health, achievement and resilience and can buffer against depression and anxiety.” 

Martin E. P. Seligman, director of the Penn Positive Psychology Center

In order to deal with depression, some lifestyle changes are critical. Depressed thinking develops a set of habits and behaviors—ways of thinking and feeling—that need to be replaced. We enable the interacting body and mind to reinforce positive ways of thinking and feeling by making deliberate choices in how we live. That’s not to say it is easy, but it can be done. In particular, a depressed person would do well to evaluate four aspects of his or her lifestyle—exercise, diet, structure and sleep—before taking medications, because these four behaviors have a direct bearing on brain function (see “Before You Medicate”). 

Why Not Prevention?

If the majority of depression can be worked with to achieve a positive outcome, is it also possible to influence the mind so as to prevent a depressive inclination in the first place? In other words, if the brain can be retrained in the way it thinks, couldn’t it be trained to think properly from early childhood?

Every time a person gets depressed, the connections in the brain between mood, thoughts, the body, and behavior get stronger, making it easier for depression to be triggered again.”

J. Mark G. Williams, John Teasdale, Jon Kabat-Zinn, Zindel Segal, The Mindful Way Through Depression

The emphasis in the reams of depression-related material available today is on treatment, including both medication and therapy. However, this narrow focus may overlook the bigger picture. The brain is able to make connections between emotions and thoughts; it has the ability to reason with emotion and to use emotions to enhance thought.

In the 1990s, information regarding emotional intelligence (EI) began to emerge through the research of John D. Mayer, Peter Salovey, David R. Caruso, Daniel Goleman and others. They advanced principles that provide a new way to understand and assess the connections between emotions, thoughts and behavior. A general definition of EI given by Mayer, Caruso and Salovey is “an ability to recognize the meanings of emotions and their relationships, and to reason and problem-solve on the basis of them. Emotional intelligence is involved in the capacity to perceive emotions, assimilate emotion-related feelings, understand the information of those emotions, and manage them” (“Emotional Intelligence Meets Traditional Standards for an Intelligence,” 2000). Some researchers even suggest that people’s emotional intelligence quotient (EQ) may be more important to overall success in life than their IQ. The ability to control and manage emotions is critical, particularly in those areas of life that produce stress.

So instead of focusing only on the development of emotional maturity in adults as a means of changing brain chemistry, why not take it back to a base cause of depression: early childhood experiences, or early life stress. Dealing effectively with the epidemic of depression requires attacking the cause, not just learning to better treat the effect. This was a focus of psychologist Martin Seligman’s research as early as the late 1970s. (See “Building Resilience in a Turbulent World.”) 

It is not coincidental that the increase of depression from one generation to the next parallels the breakdown of the traditional family. If children did not experience childhood trauma, the likelihood of developing depression would decrease. Child psychologist Lawrence E. Shapiro makes this interesting observation in his book How to Raise a Child With a High EQ: A Parents’ Guide to Emotional Intelligence: “Paradoxically, while each generation of children seems to get smarter, their emotional and social skills seem to be plummeting. If we measure EQ by mental health and other sociological statistics, we can see that in many ways today’s children are much worse off than those in previous generations. . . . Many social scientists believe that the problems of today’s children can be traced to the complex changes in social patterns that have occurred in the last forty years, including rising divorce rates . . . and the diminishing time that parents spend with their children. . . . What can you do to raise children who are happy, healthy, and productive? . . . You must change the way that your child’s brain develops” (emphasis added).

The development of emotional maturity begins with the nurturing and love a child experiences within a structured family as the brain chemistry sets the patterns that will carry the child happily into adult life. A stable, loving family that teaches a child self-discipline and self-control helps set the child’s emotional biochemistry, allowing him or her to be more in control of life. Broken homes, single-parent families, divorce, abuse and violence all affect the development of neurotransmitters such as serotonin as neural pathways are formed.

So can the paralyzing effects of this widespread condition be prevented? Ongoing research indicates that the fight against the rising tide of depression and mood disorders begins with a proactive approach to effective child development. Children who are raised to attain strong emotional maturity may in fact help stem the slide into the generational increase of depression. By all means let’s find ways to more effectively treat those with mood disorders, but let’s also focus on prevention as a significant part of the cure.