The Many Faces of Depression

Understanding the Malware in the Brain

Please delete the malware in my brain—thoughts not mine keep downloading—delete delete delete (me?)—It slows me down it drags me down it glitches glitches me.” 

Kirstin Emilie, “Depression” (Facebook, May 2021)*

Depression is one of the world’s most common and debilitating disorders, and arguably the most undertreated. The persistent myths, stigma and questions surrounding depression can make it hard for us to recognize and care for it—in ourselves or our loved ones.

C.S. Lewis commented on this conundrum in his 1940 book The Problem of Pain. “Mental pain is less dramatic than physical pain, but it is more common and also more hard to bear,” he wrote. “The frequent attempt to conceal mental pain increases the burden: it is easier to say ‘My tooth is aching’ than to say ‘My heart is broken.’”

Of course, equating depression with a broken heart doesn’t tell the whole story. Depression comes in all forms, hitting when and where it hurts most. It touches each person differently, with different symptoms and reactions, so that it can be difficult to parse from the ordinary, natural emotional responses to challenges we face in the normal course of life. To complicate things further, some may wear a happy mask—whether to avoid feeling like a burden, or to prevent the potential for well-meant but unwelcome advice.

So what does depression look like? Who does it strike? What causes it? Can it be cured or prevented? And why do people have such a hard time talking about their own experience of it?

Depression . . . affects a person’s capacity to think clearly; undermines motivation to act; alters intimate bodily functioning, such as sleeping and eating; and leaves a person feeling stranded in the midst of searing mental pain and suffering he or she feels unable to do anything about.”

Zindel V. Segal, J. Mark G. Williams and John D. Teasdale, Mindfulness-Based Cognitive Therapy for Depression

The reality is that feeling distressed doesn’t equal being depressed. We might simply be responding normally to the grief of losing a loved one after a death or divorce. We might just be languishing (as opposed to flourishing) during a pandemic lockdown, a long winter without sunshine, a job loss, chronic pain or disability, caring for a disabled relative, or some other situation that has us looking down a dark tunnel without much visible light at the end. We might be laboring as best we can under persistent interpersonal mistreatment. We might be physically exhausted from childbirth, its attendant new pressures, and a resulting lack of sleep.

Or we might truly have one of the many forms of depression that can be triggered by one (or more) of these circumstances. And let’s acknowledge an important truth: it’s not such a rare thing to be faced with multiple adverse events at once.

Social media memes offer simplistic solutions: Keep a gratitude journal. Go for a jog. Get outside; be with people. It’s not that these aren’t great strategies for maintaining overall mental health; they are. But cures they are not.

Even less helpful are the cheerful admonitions of friends: “It’s a beautiful day! Cheer up! You just need to remind yourself other people have it worse! It’s all in your head! Try not to dwell on the negative!” If you’re otherwise healthy and wanting to shore up your emotional intelligence, then okay, you can probably do something with that advice. But if you’re clinically depressed? Solutions like these are not on point.

Perhaps most of us could use a bit more understanding about the nature of depression before offering the blithe advice we might give to a healthy person who is simply having a bad moment or a bad day. This isn’t bad advice for most people. It’s just not the best advice for people with depression.

What Depression Looks Like

What you and I call depression is most often clinically known as major depressive disorder (MDD), although there’s a whole family of related disorders. To a clinician, of course, what depression looks like is going to be somewhat different than what it looks like from the sufferer’s perspective.

What it looks like to policymakers is different again. Policymakers like statistics, and depression statistics are both plentiful and confusing—as well as a bit, um, depressing. The most oft quoted statistics describe the prevalence of MDD in a given population over a 12-month period, since public-health policy generally relies on annual figures. In 2020, the World Health Organization estimated the global number of sufferers at 264 million (more than 3 percent of the world’s population). But this is almost certainly an underestimate because of the stigma that prevents many from seeking help—perhaps especially men, as we’ll see. Although, as with any illness, some cases probably fall on either side of accurate diagnosis, MDD is unquestionably common worldwide.

Those who have been depressed know that there is no single face to the disorder, no single feature that tells the whole story.”

Zindel V. Segal, J. Mark G. Williams and John D. Teasdale, Mindfulness-Based Cognitive Therapy for Depression

Clinicians identify depression using diagnostic manuals, along with assessments based on those manuals. The two most widely used are the Diagnostic and Statistical Manual of Mental Disorders (DSM), which is currently in its fifth edition, and the International Statistical Classification of Diseases and Related Health Problems (ICD), currently in its 10th edition, with the 11th scheduled to take effect in January 2022. But while the two manuals aim for consistency with one another to avoid unnecessary confusion, both fall short in clearly diagnosing MDD.

To begin with, both the DSM-5 and the ICD-10 are limited in their ability to distinguish between mild depression and normal mood fluctuations. This weakness became apparent in a number of clinical studies, which found that using antidepressants to treat patients diagnosed with “mild MDD” was no more beneficial than treating them with placebos. On the other hand, antidepressants have proven effective in moderate and severe cases of MDD. This suggests that “mild MDD” isn’t really an abnormal mental state at all. In other words, if the fix isn’t fixing anything, it must not be broken; maybe the person in question is just having a normal emotional response to a difficult situation.

And what about the term itself: “mild major depressive disorder”? If it seems like an oxymoron to you, you’re in good company; many of those who have spent their working lives studying depression would agree. In the words of two such researchers, Allen Frances and John Nardo, “mild major depressive disorder is a contradiction in terms—often not ‘major’, not ‘depressive’, and not ‘disorder’.”

Disagreements over the manuals’ diagnostic criteria aren’t uncommon. For instance, the DSM-5 board removed an exclusion for bereavement from the criteria for MDD. Frances and Nardo argued that instead of removing the exclusion, they “should have considered extending a similar exclusion for sadness and other mild ‘depressive-like’ symptoms in the face of other severe life stress such as divorce, job loss or financial troubles.”

DSM-5 has lowered the thresholds of existing diagnoses—making it far too easy to diagnose major depressive disorder in people experiencing normal grief.”

Allen J. Frances and John M. Nardo, “ICD-11 Should Not Repeat the Mistakes Made by DSM-5” (2018)

This is not to say that mild depression should be ignored. Those who meet most but not all the criteria necessary for an MDD diagnosis may have a heightened chance of eventually meeting them all. Psychologists refer to this as subsyndromal depression, but unfortunately definitions are currently inconsistent, which makes it difficult to predict who might be most at risk.

Another challenge to successfully diagnosing depression lies in the fact that what’s considered normal in some cultures can be seen as abnormal (and a sign of depression) in another. For instance, research finds that European Americans tend to avoid negative emotions, while many Europeans view them as a natural part of life’s experience. In some areas of the Middle East, the symptoms that indicate someone is falling in love might look like depression to a Westerner. Across cultures, in other words, it’s important to consider what might be a normal reaction in a given cultural context before labeling someone with MDD.

Who It Strikes

Depression can afflict just about anyone, but it strikes those living under the poverty line nearly twice as frequently as those above it, and women nearly twice as frequently as men.

The relationship between poverty and depression is somewhat of a cycle: poverty can increase the potential for depression and other mental illnesses—and experiencing these debilitating conditions can, in turn, contribute to sending people further below the poverty line and trapping them there.

The gender gap in depression is also complex, and part of it seems to be culturally based. Men are not immune to depression, of course, but in many cultures, men aren’t encouraged to show vulnerability to “softer” emotions such as anxiety and sadness. On the other hand, anger and aggression are often considered more stereotypically masculine emotions, which may be why substance abuse and antisocial behavior tend to be more common among men, while anxiety and depression, often occurring together, are more common among women. While there may be hormonal influences in some types of depression (premenstrual, postmenopausal or postpartum depression, for instance), this doesn’t fully explain the gender gap.

In fact, when data from different countries and cultures are compared, the evidence points more strongly to social factors. One of these has been dubbed “the cost of caring.” In many cultures, women and adolescent girls score higher than men on assessments that measure the value they place on interpersonal connection, although valuing relationships is by no means an exclusively female trait. The truth of that notwithstanding, it’s well documented that—even in Western cultures that are considered relatively egalitarian—women still carry the lion’s share of household chores and family caretaking.

Considering how many women struggle to balance work and family, it’s not surprising that researchers find that excessive concern about their relationships can sometimes lead women (more often than men) to care for others to the point of neglecting their own needs—a situation that can certainly contribute to depression. This only gets worse when women are expected to be perfect in all these roles (wife, mother, housekeeper, employee). Perfectionism is strongly linked to the risk for severe depression.

The cost of caring isn’t only a result of excessive concern for others, though. Even valuing their relationships in perfectly healthy ways seems to make women more vulnerable to depression. Developing strong, supportive social bonds is a good thing, right? Even a great thing. There’s no question that being surrounded by responsive, encouraging friends and loved ones is a healthy lifeline in difficult times. But because most women tend to feel emotionally invested in a wider network of these connections than many men, the chances are higher that hardship will strike someone important to them—which, of course, makes them vulnerable to loss and affects their own well-being.

In keeping with that higher chance, women actually do report more such events within their networks than men do. It would be a mistake to put this down to mere emotional sensitivity. Early childhood adversity has been found to sensitize girls (more than boys) to subsequent stress, but that first adverse event for girls also has a higher chance of being severe (and therefore more likely to sensitize) compared to the first adverse event for boys. While both boys and girls experience childhood sexual abuse, for instance, rates for girls tend to be higher than for boys. And while divorce and other forms of family disruption are difficult for everyone involved, research suggests that these events, including any maternal stress that children observe, often affects girls disproportionately.

It’s important to note that men are sometimes the sole family caretaker for elderly parents or a disabled spouse; when that happens, they, too, are subject to an increased risk for depression. And men in high-caregiving jobs (firefighters and emergency medical service [EMS] personnel in particular) have significantly higher rates of depression and suicide than the general population.

[More than one-third] of fire and EMS professionals have contemplated suicide, nearly 10 times the rate of American adults.”

Substance Abuse and Mental Health Services Administration, “First Responders: Behavioral Health Concerns, Emergency Response, and Trauma” (2018)

All of these considerations suggest some intriguing questions: If the “cost of caring” were more equally shared, and if it were more acceptable for men to show vulnerability to emotion, would we see more similarity in rates of depression across genders? Perhaps even lower rates in general because of shared support, understanding and expectations?

Causes, Cures and Prevention

What causes depression? Again, there are no simple answers. Certain medical illnesses (hypothyroidism, Parkinson’s disease and Huntington’s disease, for instance) are known causes. There are also biological and environmental influences. Depression has been well linked to stressful life events including abuse, demanding conditions (including climactic ones), scarcity (including poverty and lack of social support), and loss of all kinds (including loss of employment and, of course, loss of a loved one; loss of identity is sometimes overlooked in the “loss” department but is on par with any other).

Because depression is often seen in the company of other disorders, it can be difficult to identify which came first. About three-quarters of those diagnosed with MDD will be diagnosed with at least one other mental health disorder over their lifetime, with anxiety being by far the most common.

Depression also occurs with many medical conditions—although whether as a cause or an effect is not always clear. In fact, the division between our physical and mental states is somewhat arbitrary and even artificial. Are we bodies with brains or brains with bodies? Does our mental state determine our physical state, or vice versa? This is perhaps the classic chicken-and-egg question. In fact, the body and brain are linked by the parasympathetic nervous system, of which the vagus nerve is the central moderator. The upshot is that what happens in the brain doesn’t stay in the brain, and what happens in the body doesn’t stay in the body. And (dare we say it) what happens in the vagus doesn’t stay in the vagus.

Even appreciating the fluidity between our mental and physical inner workings, we may forget that—despite our seeming individuality—no single one of us is a closed system. We’re connected interpersonally with other minds, which are connected to other bodies. With this in mind, some have objected that the DSM’s list of depression symptoms focuses primarily on intrapersonal descriptions (what’s going on within the individual), while ignoring interpersonal symptoms that are well established by research (such as social dysfunctions and impaired communication with others).

Considering the myriad causes of depression, it makes sense that treatments are usually approached on multiple fronts, often using medication combined with a therapy chosen to address the specific factor that’s causing a person to stay depressed. The wide success of cognitive and behavioral therapies in treating both depression and anxiety speaks to the fact that, yes, the brain’s “glitches” can be reworked.

Cognitive behavioral therapies focus on helping patients identify and address patterns of thinking and/or behaving that can be changed even when external events can’t. Among these are Cognitive Therapy (CT), Mindfulness-Based Cognitive Therapy (MBCT), Trauma-Focused CBT (TF-CBT) and a host of others. These treatments have strong research support, and each has its strengths. For instance, CT has been shown to be as effective as antidepressants, and apparently more enduring. If antidepressants are used, it turns out they are more effective when combined with CT than when used alone. MBCT has an outstanding track record for preventing relapse or recurrence. Behavioral Activation (BA) and Problem Solving Therapy (PST), two therapies that focus on a patient’s environment, behavior or specific problems (rather than on thought processes per se), have also proven effective.

But for maximum benefit, all such cognitive and behavioral therapies should be guided by someone who is familiar with applying them successfully. And they take time. Curing depression is not just about waking up one day and deciding to think and behave differently.

So where does prevention come into the equation? Some would say it’s unrealistic to think that we can always prevent everything, and there’s some truth to that. We can do our best to offer one another the personal and community support needed to build a good foundation for mental health, but we (and those close to us) don’t have control over all the biological, environmental or interpersonal influences in our lives.

Having said that, there is good evidence that perhaps as many as 50 percent of major depressive episodes could be prevented. Ideally the goal would be to prevent the first episode, since the chance of recurrence increases with each subsequent one. Here again, just as with treatment, CT shows promise in preventing first occurrences of major depression.

The point of cognitive and behavioral therapies is to identify and rewire the pathways used by the automatic and intrusive thoughts that “glitch” the brain. “Please delete the malware in my brain—thoughts not mine keep downloading” writes a young woman on her Facebook feed, describing an experience that so many others can relate to. “Depression isn’t who I am (even if it does feel like that sometimes),” she contends. And she’s absolutely right. The good news is that the brain’s “malware” can be deleted—without deleting the parts of us that make us who we are.