How often does a depressed person hear comments such as these?

“Just smile.”

“Do something and you'll feel better.”

“If you just stop being so negative, you wouldn't feel so bad.”

“I don't know why you're so depressed. You have everything.”

Some of these comments may be well-intentioned but they show a lack of understanding of the nature of depression. The problem is rooted in the use of the word “depression” as a diagnosis. The reason this is a problem is due to the word “depression” also being used by the public to describe a mood such as “I'm feeling depressed today.” However, a temporary mood and a diagnosable illness are two very different things. So the use of the same term to describe apples and oranges creates a great deal of confusion and misunderstanding.

It certainly would make sense if we could change the name of the diagnosis to something else: “XYZ Disorder” that wouldn't have any other association in the public's mind. However, this was tried by the mental health profession in the past when they changed the diagnostic term manic-depression to bipolar disorder. At the same time they changed major depression to unipolar disorder but it wasn't accepted in either the public's mind or the profession's. Therefore, the best we can do at this point is to try and distinguish between the diagnosable conditions of depression and the common use of the word “depression.”

WHY IS THIS A PROBLEM?

The misunderstanding occurs because just about everyone has experienced sadness or “feeling down.”

If the public calls this temporary mood state “depression” they will erroneously believe that they know what it feels like to be depressed in the clinical sense of the word. However, they will be wrong! Even though they are wrong, it won't stop them from making certain assumptions and comments that can be very detrimental to people who have a diagnosable condition.

In particular, they are likely to have beliefs or even make comments such as “When I was depressed, I just snapped myself out of it” or “Depression is just a matter of attitude.” Certainly, these comments may relate to a temporary mood state, but they do not apply to the depressive disorders. Not only that, but saying these types of things to a depressed person can only serve to make them feel worse.

People with clinical depression have lived with this societal attitude, and therefore, many of them believe the same thing. They frequently believe that only if they tried harder, they wouldn't feel so bad. They may believe that the depression is somehow their fault. They may believe that they are weaker than others because they can't handle the normal stresses of life that other people can. All of these beliefs are wrong!

However, these critical attitudes can make the depression worse. It is difficult enough for a person to manage the depression without having the additional stress of feeling like a failure.

WHY DOES IT SEEM THAT DEPRESSION IS CAUSED BY STRESS?

The fact is that the depressive disorders, as is true of most of the physical disorders, are reactive to stress. This is due to the physiological impact of stress as well as the psychological impact. For instance, if a person has the common cold, their body will marshal the defenses such as producing white blood cells, adrenalin, and cortisol to fight the invading germs. When the body does this it requires additional energy and it reduces the functioning of other systems to obtain this energy. Therefore, a person will feel fatigued and will tend to be less active.

This normal process serves to help the body recover. But what if the person is stressed in other ways? What if the person has chronic back pain? What if the person just lost his job? What if the person has to take care of someone else even though she's sick? Or, what if the person has a combination of additional stressors. In such a case, the body is needing to divide its resources to fight the effects of all these stressors.

The problem is that we only have so much in terms of physiological resources. In addition, the psychological impact of stress is that a person finds it more difficult to do the necessary self-care. With a common cold, for example, it may be hard to obtain the necessary rest. As a result of the physiological and psychological factors, it becomes more difficult to recover from the common cold.

This same process occurs with clinical depression. The more stressors in a person's life, the more difficult it becomes to recover from the depression. Therefore, many people will tend to associate the presence of these stressors as the cause of the depression. However, that is not the case. The stressors may impact the depression and make it worse or more difficult to recover, but they are not typically the cause. In fact, if a stressor is the cause, it is likely a different condition known as an adjustment disorder rather than depression which we will discuss later.

What makes the picture even more confusing is that some of the suggestions at the beginning of this article that people make actually DO help. They can help because they help reduce the impact of stress. The more stress and the effects of it are reduced, the more the body can fight the depression.

However, those sorts of suggestions and comments without a full understanding of clinical depression become detrimental rather than helpful because they can be seen as an attack which is just another stressor for the depressed individual.

WHAT IS CLINICAL DEPRESSION?

A psychiatric diagnosis can be very confusing because most diagnoses are not true disorders or illnesses but just a list of symptoms that tend to occur together. A true disorder or illness is when the cause can be identified such as a particular type of cancer being linked to specific genes. Therefore, most psychiatric diagnoses describe a group of possibly unrelated conditions or illnesses that may have different causes. Keep in mind that the descriptions of these disorders provided below may actually involve more than one illness.

The three primary types of depressive disorders are major depression, dysthymic disorder, and bipolar disorder. In addition, people may suffer atypical depressions which may be associated with medical conditions, child birth, or drug/alcohol use. Finally, depression may be associated with other mental conditions such as schizoprenia. In this article, the focus is on the three primary types.

1) Major Depression.

Major depression is diagnosed when an individual suffers significant symptoms that interfere with life functioning such as work, school, or daily activities of living. The symptoms must be present a minimum of two weeks.

The symptoms include depressed mood, sleep disturbance, appetite disturbance, fatigue or loss of energy, feelings of restlessness or lethargy, lack of interest or pleasure in most activities, impaired concentration and ability to make decisions and feelings of worthlessness and guilt.

A common symptom of major depression is suicidal ideation which involves thoughts of death, a desire for death, or the belief that others would be better off without them. Although this is a common symptom, most people with major depression do not attempt suicide for various personal or religious reasons.

However, suicidal ideation is a very serious symptom of major depression. Approximately 30% of people with major depression attempt suicide and 15% commit suicide. Those who have had more than one major depression are particularly at risk. Due to the seriousness of this symptom, any suicidal ideation or talk needs to be immediately evaluated by a professional. Family and friends should not assume that it is not serious. A professional needs to evaluate it.

2) Dysthymic Disorder. While not quite as acute or debilitating as major depression, dysthymic disorder significantly interferes with the quality of a person's life. Dysthymia tends to be a low-grade but chronic condition. In other words, the symptoms are not as severe as major depression, but they tend to be always present. In fact, the diagnosis of dysthymic disorder requires that the symptoms must be present for a majority of days for at least two years.

The symptoms of dysthymia are much the same as the symptoms for major depression but are not experienced to the same degree. An unfortunate consequence of dysthmia is an increased susceptibility to developing major depression. However, treatment of the dysthymic condition especially with cognitive-behavioral therapy (CBT) methods decreases the risk of developing major depression.

Although any suicidal ideation needs to be taken seriously, the risk of suicide for someone with dysthymic disorder does not appear to be any more than that in the general population. However, a person with double-depression which is the combination of dysthymic disorder and major depression has the same suicide risk as indicated above for those with major depression.

3) Bipolar Disorder.

Bipolar disorder is a condition in which a person will alternately experience the symptoms of depression as described above with states of mania. Mania is a mood state in which the person experiences an extravagant style, grandiosity or expanded self-esteem, reduced need for sleep, excessive or pressured speech, racing thoughts and ideas, and excessive self-indulgence in risky, but enjoyable, behaviors such as sex, gambling, or business schemes.

Frequently, the person in a manic state may experience psychosis in which there is no awareness of the inappropriateness or riskiness of the behaviors. Family members, co-workers, and friends may be much more concerned about the manic behavior than the individual him/herself may be.

Although bipolar disorder almost always requires medication to control the symptoms, CBT can be a helpful adjunct to assist in managing the stressors that can trigger episodes.

WHEN IS DEPRESSION CAUSED BY STRESS?

Although the above conditions appear to be biological conditions that are caused by genetic predispositions, some people may experience temporary symptoms of depression due to stress. Such a condition is typically diagnosed as an adjustment disorder with depression or in the case of a traumatic experience may be diagnosed as an acute stress reaction.

An adjustment disorder may involve the depressive symptoms but the symptoms can be traced to a single event or a period of stress in a person's life. In addition, an adjustment disorder is not likely to be recurrent unless triggered by other events or periods of stress. However, this condition should not be confused with a depressive illness which has an underlying biological cause as we understand it today.

An adjustment disorder, in particular, can be very receptive to CBT methods since these methods directly impact the ability to cope with stress. In addition, practicing stress management methods and addressing daily stress is likely to be helpful in preventing the occurrence of an adjustment disorder.