Depression Is Much More Than A Few Bad Days

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.