Depression is horrible and sometimes it's deadly. Data from the World Health Organization demonstrates this serious public health issue: depression affects 350 million people worldwide and nearly a million lives are lost yearly due to suicide (about 3000 suicides each day). Yet depression is misunderstood by those who have never experienced it because they can't understand why depressed people don't just will themselves better. It's also misunderstood by many who have lived it and can't understand why they couldn't make themselves better.
Let's consider Lynn, a fictional patient who is a newly divorced mother of two and works full time. She went to her family doctor complaining of "exhaustion" and struggling to get out of bed in the morning. The usually gregarious Lynn reported she was crying "over every little thing" for months and couldn't recall when she last felt happy. Recently, she was mortified when she burst into tears at work, prompting the visit to her GP.
Lynn had stopped seeing her friends and wasn't going to exercise class. She had frequent debilitating headaches and was worried she might have a brain tumor. She told her doctor, "I don't think I'll ever be happy again. My kids might be better off without me". Her physical exam and lab work were normal. Lynn completed a mood questionnaire and scored in the severe range for major depression.
Nearly all depressed patients experience changes in their sleep patterns and appetite.
Major depressive disorder (MDD) is a medical illness that is usually associated with profound sadness, although some depressed patients say they are numb or feel no emotion at all. There are two main criteria required to make a diagnosis of MDD: depressed mood and/or anhedonia (experiencing little or no pleasure from usually enjoyable activities). In my experience, anhedonia is a more powerful indicator of MDD than sadness.
MDD includes a constellation of emotional, physical and cognitive symptoms that cause suffering and impact functioning at work or school and at home. Emotional symptoms are what most people think of as depression: sadness, anhedonia, hopelessness, and worthlessness. However, the other symptoms of depression are also distressing and impairing. Physical experiences like body pain, headaches or upset stomach are exceeding common and can confuse the diagnosis and delay treatment.
Nearly all depressed patients experience changes in their sleep patterns and appetite. Some have insomnia: the inability to get to sleep, stay asleep or awakening too early. Others sleep too much, complaining that they could sleep day and night. Some people experience a complete loss of appetite, while others feel ravenous, often craving carbohydrates, especially at night.
The majority of depressed patients experience cognitive symptoms. These include memory and concentration problems and feeling slowed down, mentally and physically. Cognitive symptoms can occur at any age and are sometimes so severe patients worry they are developing dementia. The term "pseudo-dementia" is sometimes used to describe an elderly depressed patient who appears to have dementia but their cognitive symptoms are related entirely to depression.
Anxiety is a particularly dreadful symptom of depression.
The symptoms of depression are persistent and present for the majority of the time for at least two weeks. However, most people don't seek help until the symptoms have been present for months or even years. Women are twice as likely to develop depression but it's not entirely clear why.
Those who haven't experienced depression says things like, "We all have bad days," or "Sometimes we all get down," but depression is not simply a bad day. Mental illnesses are potentially deadly. Depressed patients often feel sad but also anxious, ashamed, hopeless, and worthless. Sometimes these feelings are intolerable and suicide represents a potential escape from the emotional pain. For some, the idea of suicide comes almost as a relief. They might think that suicide will release loved ones from the burden of living with a depressed person. This is what depression does: a depressed brain tells itself the terrible lie that all is hopeless and recovery is impossible.
Anxiety is a particularly dreadful symptom of depression. Anxiety symptoms may include negative ruminations like "everyone hates me" or "I'm useless," but also worry about everyday issues like health or finances, or they may be experienced physically with symptoms of chest pressure, restlessness or muscle tension. Anxiety drastically heightens the risk of suicide in MDD, although anxiety symptoms are sometimes incorrectly dismissed as less serious than depression symptoms.
The causes of MDD are similar for all mental illnesses: biopsychosocial (see my March 21 blog). MDD runs in families, but chronic life stress and coping skills are extremely important in the development and persistence of depression. Stress alone doesn't cause depression, but it is common for the first episode to follow a stressful experience, like an unexpected death, divorce or job loss. With each episode of depression, stress becomes a less critical provocative factor but continues to heighten the risk of relapse.
MDD can become a chronic and progressive illness, likely related to the development of inflammation. Prolonged stress can result in chronically high levels of cortisol, the brain's major stress- management hormone, which can trigger an inflammatory response that damages neurons and support cells (glia) in specific brain regions. Those damaged cells then provoke even more inflammation. This inflammatory process has been well documented in chronically depressed patients but it can also occur in patients with a severe first depression.
If depression is not treated quickly and fully, the brain injury can become chronic and less responsive to treatment. With each depressive episode, the inflammatory process may progress, resulting in serious cognitive and functional impairment. This demonstrates the power of a seriously stressful event, like divorce or job termination, which may, in vulnerable individuals, cause serious biological consequences.
Depression hurts, mentally and physically, and it's all the more painful when the stigma of mental illness forces those with depression to hide and feel ashamed. We don't celebrate the recovery from depression like we do the recovery from cancer, yet both are serious medical illnesses and both are potentially deadly. Until we accept the fact that mental illnesses are medical illnesses, depressed people will suffer two hits: the illness and the stigma.
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Do you have persistent feelings of sadness or hopelessness that have lingered for at least two weeks and occur throughout the day, every day or nearly every day? Are these feelings interfering with school or work, or your relationships? This is a key symptom of clinical depression. We all have negative thoughts from time to time, and it’s natural to be sad when there is a serious event in our lives, like a death. The difference with clinical depression is that the feelings stick around and interfere with your ability to live your life day to day.
Many people with depression find it difficult to get out of bed — and we're not just talking about hitting the snooze button. For some, getting up seems nearly impossible. They may also find themselves spending unusual amounts of time in bed throughout the day, or having trouble with normal activities because of fatigue.
As tired as you may be, if you’re depressed you might also have trouble sleeping. Marked changes in sleeping patterns, like insomnia or increased time spent sleeping, is another symptom of clinical depression.
Some people either gain or lose weight when they have clinical depression because of their change in appetite. For some, this means an increase in appetite and possibly weight gain as a result. Others lose their appetite and struggle to eat much at all. In either case, a significant change is worth investigating.
We all have times when we feel a bit more introverted than usual, but when people have clinical depression, they can lose the sense of pleasure they used to get from their favourite activities or from engaging with others. This isolation can make it harder for friends and loved ones to see the other symptoms of depression a person may be exhibiting, which makes it more difficult to know when a person needs help.
It’s more often thought of as a symptom of ADHD, but an inability to concentrate or hold focus on one’s activities can be a sign of clinical depression. Of course, if someone with clinical depression is also having trouble sleeping, not eating well or has lost interest in regular activities, this symptom can be amplified.
This is the most serious symptom of depression, says Dr. Joe Taravella, a psychologist and the supervisor of Rusk’s Pediatric Psychology Service at NYU-Langone Medical Center in New York. “When you’re severely depressed, suicidal thoughts can become so prominent, you begin to make a plan for ending your life, as you feel there are no other options.” If you are experiencing suicidal thoughts, seek help or tell a trusted person in your life and ask for help — call your doctor, call 911, or go to an emergency room. And never assume that a person who talks about suicide won’t do it. If someone tells you they are feeling suicidal or discusses plans to end their life, always take it seriously and get help.
“Many people don’t realize that low levels of chronic irritability and anger can mask an underlying depression,” Taravella says, “which can be undiagnosed and untreated for years.” A study released last year found that more than half of men and women who were experiencing a major depressive episode reported irritability as a symptom. Constant irritability is also a symptom of depression seen in teenagers and children, one that could be written off as normal growing pains or teenage behaviour.
Yes, depression can literally hurt. There is increasing recognition of the physical symptoms of depression, which include headaches, stomach pain, and back pain. One study found half of patients with depression from around the world reported unexplained physical symptoms. But because these physical symptoms are often vague or have no logical explanation, they can be missed as as symptom of depression.
For people with severe depression, basic tasks of self care can seem too overwhelming to undertake, Taravella says. As well, personal hygiene may seem unimportant if you are feeling hopeless or worthless. If someone in your life is showing a marked decrease in personal hygiene, don’t assume they are simply lazy.
Going along with trouble with concentration, people with clinical depression often have memory issues that can add to their difficulties in maintaining day-to-day activities. “As a result of these symptoms, they are more likely to become inattentive to their environment and prone to falls and injuries,” he adds. A 2013 study found that this could be because clinical depression impairs the process of “pattern separation,” which is the ability to distinguish between things and experiences that are similar.
Some people who show signs of depression engage in what Taravella refers to as “externalizing behaviours,” which include substance abuse and risk-taking activities. Men are more likely to do it, he says. These behaviours can be a sign of an underlying mental-health problem, particularly if they’re out of the ordinary for the individual.
“If you recognize symptoms of depression, take action and immediately seek professional help,” Taravella advises. There are valuable resources out there, he says, including psychotherapy and antidepressants. Many people also find some relief with meditation and exercise, often in conjunction with other treatments. It can be difficult to navigate the process of finding the right help, especially if you are having trouble just getting out of bed. Try talking to a trusted friend or family member who can help you research options and even call a therapist for you.
It can take time for depression treatments to start making a difference, which is frustrating when you've taken the difficult step of admitting you need help. But while you work on medication and/or therapy, there are things you can do. Be as active as you can, Taravella says, and try to see friends. “Create small goals for yourself each week but don’t put a lot of pressure on yourself,” he suggests. While it can take time for depression symptoms to begin to lift, it may be worth seeking different treatment options if you are not seeing any improvement after two months.
“The best way to help someone who is depressed is to be a constant source of support for them,” Taravella says. This can sometimes be difficult, however, because people with depression tend to isolate themselves despite your efforts to stay in touch and/or get involved. You may also be able to help someone by making a doctor’s appointment for them. It’s a simple task to request an appointment, but for someone who is severely depressed it can seem incredibly daunting.
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