25 March 2003

Depression [or substitute any major "disorder" here] isn't really caused by specific events or issues

It happens when 1. you don't have the resources necessary to cope with something, or 2. you are somehow thwarted in meeting the basic needs/resources necessary for moving towards self actualisation

Please note: The initial thrust behind this entry was to conceptualise depression in terms of an inability to cope with life stressors. I will soon be revising this entry to include depression which occurs as a result of difficulties in self actualisation (the process of getting certain basic needs met such that you can become the person you were meant to be, to become all that you can, etc...).  Actualisation is a process which has become ingrained in the brain because it evolved in order to ensure survival of the species. It is noted that in many cases, depression is not necessarily a "disease" process and that it does, indeed, serve an important purpose (e.g., it allows us to cope, to seek assistance from others, to motivate ourselves for changes in order to escape its painful presence, to numb ourselves from painful anxieties and stressors, and to shut the mind and body off in times of acute stress).

When they see someone who is depressed, it seems to me that people often make the mistake of believing that it's a given issue/dilemma/problem that has made that person depressed. "Of course he's depressed," the say. "I would be too if I were going through that same situation." What I often find myself doing is drawing people's attention to the fact that most people are actually fully able to negotiate a wide range of difficult—even traumatic—situations, issues, or conflicts without subsequently slipping into a major depression.

Of course, before I continue I should mention specifically what it is that I mean when I use the term "depression". I differentiate depression from regular, normal emotions/reactions like sadness, grief, mourning, disappointment, frustration, exasperation, etc. Depression refers to a whole constellation of physical, cognitive, and emotional symptoms which affect the entire mind and body and significantly interfere with a person's everyday functioning. The symptoms include two or more weeks of five or more of the following: significant feelings of depressed mood for most of the day, almost every day; loss of interest/pleasure in daily activities; significant changes in eating/sleeping patterns; psychomotor agitation or retardation; fatigue almost every day; excessive feelings of worthlessness, hopelessness, or guilt almost every day; really hard time thinking/concentrating; recurring thoughts of suicide/death; etc. Because the above symptoms tend to cluster together a lot, depression appears to exist as a unique, discrete entity (it is, in other words, a "real thing").

So, based on the above, it would seem that most people who experience significantly upsetting events do not go on to slip into a full-fledged depression or other syndromes (see, for instance, G.A. Bonanno, Loss, Trauma, and Human Resilience, in American Psychologist, Vol. 59, No. 1. For instance, most people who experience a death in the family become extremely sad but do not go on to become depressed. As another example, most people who experience serious romantic, family, sexual, or career issues do not go on to develop depression. Even many people who are physically or sexually assaulted, of who witness the traumas that other people go through, do not go on exhibit the symptoms of clinical depression.

On the other hand, there are some people who become devastated and slip into a depression after experiencing what most of our would consider "minor" stressors, events, issues, or conflicts. What makes these two groups of people different?

It seems that the difference lies in people's ability to cope. And it seems to be that to be able to cope with anything, a person needs to have certain basic resources and to have certain basic human needs met. People who don't have these resources—or who don't have these basic needs met—seem unable to cope and, subsequently, they slip into depression. And of course, this would make sense if we consider that depression itself offers a person an opportunity to gather one's resources* in order to devise a more effective coping strategy (depression itself is not a good coping mechanism, especially for the long term!). Indeed, depression seems not only to remind us that we need to get certain basic resources and needs met, but it also allows us to conserve energy in order to accomplish this.

*Note: Perhaps one of the mechanisms involved in this energy conservation is the self-pitying quality of depression in which a person feels excessively sorry for himself. The reflexive response is to do whatever one can to take care of himself, much like a parent would a baby. In this sense, depression represents an opportunity for a "return to the womb". This return can itself be very invigorating (or at least provide an opportunity for a person to back away from whatever stressors have been so overwhelming in his life).

Basic human needs, resources, and coping skills

So, what exactly are these resources/needs? I base my list on much of what Abraham Maslow considered when devising his "hierarchy of needs". In my mind, if a person is really missing one of the following things—or if he is missing a wide variety of them—it will become increasingly difficult for him to cope with life's challenges. Here is the list:

Again, when any of these basic things are missing, coping with even the most routine challenges in life can be very difficult (and indeed, coping with major challenges becomes impossible and then depression ensues).

*Note: Maslow's definition of self-actualisation: It is the pinnacle of the hierarchy of needs. "A musician must make music, an artist must paint, a poet must write, if he is to be at peace with himself. What a man can be, he must be. This is the need we may call self-actualization ... It refers to man's desire for fulfillment, namely to the tendency for him to become actually in what he is potentially: to become everything that one is capable of becoming..."

Actually, expanding on the above ideas, I should say that there are actually 9 general pathways through which depression occurs:
  1. When an issue, conflict, challenge, or stressor occurs and a person doesn't have the basic resources and/or skills needed to cope. Depression, then, is an expression of the brain's simple inability to cope. It is, in other words, the brain's way of saying, "I just give up."
  2. When a person merely becomes aware that she doesn't have the basic resources and/or skills needed for coping. In such cases, a person teeters on the edge of depression because she knows that if something bad were to happen, she wouldn't have all the resources necessary for effective coping.
  3. When something so bad happens that even the best coping resources and/or skills can't help us deal with it (eg, a severe stressor or trauma). In such cases, most people would become depressed. In this instance, this would be a sequelae of post-traumatic stress disorder. If the person does not recover from the trauma by himself within a reasonable amount of time, it is said that PTSD and/or depression has occurred and therapy should be initiated to help the person process and recover from the stressors (in other words, to help the person cope with the stressors).
  4. When coping resources and/or skills aren't present, depression occurs as a signal to the individual that something is wrong and must be done right away. Depression provides an opportunity to conserve energy that will be needed to gather the needed resources. In combination with #5 and #6 below, I think this helps us understand that depression may actually have a "purpose"—and, therefore, why is hasn't yet been wiped out through natural selection.
  5. Extreme stressors in the environment trigger depressive feelings and behaviours which encourage the individual to retreat from these aversive stressors. In other words, depression is an automatic safety mechanism. In combination with #4 above and #6 below, I think this helps us understand that depression may actually have a "purpose"—and, therefore, why is hasn't yet been wiped out through natural selection. "Coping", in this context, might very well mean retreating from the stressors. Knowing when to retreat from stressors is one of the coping mechanisms healthy people have. When this is absent, depression can occur as a last-ditch way of getting the person to retreat. This is not, however, an ideal adaptive strategy (ie, the person needs to develop a better way of retreating from stressors; this can be achieved in therapy).
  6. Depression occurs as a reflexive, evolutionary-based appeasement display, designed to protect oneself in interpersonal exchanges by letting the other person know that one has "surrendered". This mechanism is based in evolution and relies on lower brain as opposed to higher brain structures; it may have been adaptive for our ancestors in the jungle, but it is not adaptive today) (see my 3 January 2003 diary entry for elaboration). In combination with #4 and #5 above, I think this helps us understand that depression may actually have a "purpose"—and, therefore, why is hasn't yet been wiped out through natural selection.
  7. In rarer cases (I think), the depression starts off as a mechanism for conserving energy, retreating from a stressor, or surrendering in an interpersonal conflict (as in #4, #5, and #6), but for reasons inherent to the individual (eg, genetic predisposition), something odd happens and the depression goes on to develop a wild, full-blown life of its own, creating an entire cascade of problematic, abnormal biological events which make it nearly impossible for the individual to function at even a minimal level (let alone try to access the resources needed for coping).
  8. In rare cases, a physical brain problem. In such cases, a person has something like a serious neurotransmitter deficiency (eg, lack of serotonin) that occurs independent of anything bad happening in that person's life. Sometimes this occurs after years of drug abuse (in which normal brain pathways are disrupted). Indeed, in these cases a person may become terribly depressed for no apparent reason. These kinds of depression are called endogenous as opposed to reactive depressions (reactive depressions encompass instances 1-6 above).
  9. Any combination of the above 8 factors.
Some people are more prone to depression than others

Why is this the case?

  1. They face more stress in their lives than others (the world is more complex and complicated than ever before).
  2. They face more interpersonal conflict in their lives; as a result, they are more likely to respond using an evolutionary-based appeasement display. (This is maladaptive though, because we no longer live in a jungle).
  3. They have never really learned more effective coping skills (ie, depression is their only coping mechanism; perhaps their parents didn't teach them the right skills, or they learned from their parents that being depressed is a good coping skills when things get rough).
  4. Some people are simply predisposed to see things in a very accurate, realistic light. They are very sensitive and see the world for what it "really" is, including all its injustices, all its negatives. Instead of interpreting what they see in a somewhat "deluded" positive light, they interpret everything very accurately and realistically. The reason for this predisposition may be genetic, as a result of learning, or as a result of (extremely) negative life experiences (especially those occurring in youth). As an example of the latter, children who have been abused are more likely to see the world bleakly than are other children; it's as if growing up in an abusive, unpredictable environment primes children to be on heightened alert for future negative events (ie, these kids come to believe that seeing the world too positively might cause them to overlook future dangers, and, therefore, put themselves at risk for future violence).
  5. Some people are predisposed to ruminate on negative life events. When something bad happens, they cannot get their mind off of it and end up creating a vicious cycle from which they cannot remove themselves. The reasons for this predisposition may be genetics, learning, (extremely) negative life events (especially during youth), or even drug use which permanently pathways in the brain.
  6. In the past, they coped by slipping into depression. They just get used to it and respond in the same way whenever stress occurs.
  7. Some people have a really strong need for the kinds of basic needs/resources mentioned above (eg, very strong need for friends); because the everyday environment can't necessarily provide enough of this, they may slip into depression during stressful times.
  8. Some people are, by nature, neurologically under-aroused. As a result, they continually require stimulation and variety. When this stimulation and variety is absent they start becoming anhedonic (i.e., they feel no joy in their activities) and start ruminating. 
  9. The reason for this heightened need for the needs/resources mentioned above may come from the fact that when they were depressed earlier in their lives, these needs/resources were critical in helping them overcome it. Thus, whenever something stressful happens, they expect these needs/resources to be satisfied to the same degree that they were when they were depressed in the past (therapy can help the individual devise strategies to get these needs met, or it can help adjust these needs to normal levels by building up the person's autonomous coping mechanisms).
  10. Severe depressive episodes during youth or young adulthood somehow wire the brain in such a way that a reflexive response to stress is to become depressed. It might be that this is the reason why it seems that some people have to live with depression their whole lives (ie, they are more likely than other people to become depressed whenever any kind of stress occurs). Drug therapy can be useful in these cases.
  11. Extreme stress during childhood (including depression, abuse, traumas) causes surges in stress hormones (particularly cortisol) which damage the cerebellar vermis, which is responsible for emotional regulation. As a result, emotions become dysregulated, especially during times of stress [see Teicher, M., (2000), Wounds That Time Won't Heal: The Neurobiology of Child Abuse, Cerebrum, 2 (4), 50-67].
  12. Development of learned helplessness as a result of extreme, uncontrollable stress. In other words, feeling that you have no control over your life and environment.
  13. Through Pavlovian conditioning, depression becomes associated with stressful events in general (behaviour therapy may be useful in breaking this kind of association).
  14. Certain medical conditions have changed the structure and/or biochemistry of the brain. In other cases, hormonal abnormalities affect mood (e.g., low thyroid hormone). It might also be said that a history of drug abuse can permanently alter the brain's normal biochemistry and pathways, predisposing one to depression (especially when one does not have appropriate coping mechanisms and is exposed to significant stress). All in all, I think that medical/drug conditions directly account for only a small percentage of depression in the population. The others reasons in this list are probably more important.
  15. Some people are genetically more disposed to depression (this is probably quite rare when compared with the other reasons in this list).

For people more prone to depression than others (for the above reasons), therapy may need to be undertaken intermittently throughout life in order to fortify a person against future episodes (by helping review strategies for attaining and maintaining basic resources and skills necessary for adaptive coping). Indeed, for these people, depression as a response has become so ingrained in their brains that it may take more than one series of therapy to undue this ingraining to the point that depression is no longer an automatic response to stressors (especially if part of this ingraining is due to evolutionary factors, such as appeasement displays). For these people, depression will always be a part of their lives because even with the best therapy, there will still be remnants and traces of the old patterns of behaving.

This helps explain why people who've experienced one major depressive episode are at 30% increased risk of having a future episode; those with more than one episode are at 60% risk for a future episode; and those with three or more episodes are at 90% risk for future episodes. Even a single stretch of good therapy can help undo ingrained patterns and prevent future episodes, but in some cases one stretch will not be enough. Several will be necessary to either: 1. dismantle these patterns to a significant enough degree that future depressive episodes will be minimised (again, by reiterating strategies for attaining and maintaining basic resources and skills necessary for adaptive coping), and/or 2. help the person cope with the depression itself as much as possible (because if you can't prevent it in the first place, all you can end up doing is cope with it as best you can).

A word on what has to be done first in therapy

If we keep in mind the critical role of coping, then it should make sense that when someone sees a therapist and seeks relief from depression, the first thing that should be addressed are the basic things in that person's life—and not the specific conflicts, issues, challenges, or stressors that the person can't cope with. If the therapist can help the person develop the resources needed for coping, then it may not be necessary to even deal with the actual life events themselves; the client will be able to take care of those himself.

In some cases, though, counselling around the specific issues can still go ahead, even if coping resources and skills are fine. This would be the case for people who are fine with coping, but just need some guidance is working through the actual issue at hand. But remember: there's no way that anyone will be able to do deal with any issues if s/he lacks basic coping resources. Indeed, someone who is so depressed because of an excessive and abnormal depletion of neurotransmitters* or because of such severe lack of social support will be in no state of mind to even attend therapy or sit still in a chair in order to have a meaningful dialogue with a therapist. In these cases, what must be done are basic things like short-term cognitive approaches, finding ways for the person to develop social support (eg, join support groups), encouraging exercise and a healthier diet, helping the person get some fun in his life, giving him unconditional positive regard as a human being and encouraging him to believe in his own ability to solve his problems, and, in some cases, prescribing drugs.

*Note: Because of its severity, this depletion requires drug therapy. The severity may be because of a genetic predisposition to low neurotransmitter levels or because of the current lack of coping resources. In both cases, the depression can go on to develop a "life of its own" (it becomes, in other words, a "disorder") with a complete cascade of biological events which are troubling for the person and make it difficult for him to get the resources necessary to cope with the current difficulty. Furthermore, drug therapy may be a good idea in all instances of depression because it can be impossible to ascertain the precise mechanisms which have ultimately caused the current depressive episode. In such cases, a catch-all approach which includes talk therapy and drugs seems to be most effective.

On how to break the depressive cycle (and why it's important to do so quickly)

When it comes to this topic, the Nike dictum is right on: "Just do it."

Why has there been a rise in depression over the last several years?

In addition to better reporting and diagnosis, (due in part to increased sensitivity to problems associated with depression, and in part to reduction in stigma):

  1. People are experiencing more stress in their lives—or more severe stress—with which they either cannot cope or don't know how to cope
  2. We don't really teach people how to cope with life issues
  3. We are an increasingly isolated society, denying people opportunities for the kind of social interaction which is critical in getting us through stressful life events.

I welcome your comments on this topic.

Updated by Eddy @ 3:53 AM. Permanent link: http://www.eddyelmer.com/diary/2003_Mar_25_diary.htm