Understanding Depression

Depressive Illness: An Information Guide

On this page:

• What is Major or Clinical Depression?
• Different Kinds of Depression
• Personality Disorders and Depression

“Depression is such cruel punishment. There are no fevers, no rashes, no blood tests to send people scurrying with concern. Just the slow erosion of the self, as insidious as any cancer. And, like cancer, it is essentially a solitary experience. A room in hell with only your name on the door. I realize that every person, at some point, takes up residence in one or other of these rooms. But the realization offers no great comfort now.”

— Martha Manning, Undercurrents (1994)
author/therapist who has dealt with major depression

The pain and isolation of depression, a psychiatric illness, is difficult for many people to understand. Depression is a word that is used both for a sad, despairing mood and for a psychiatric disorder. Everyone feels sad, down or blue at times, often following a disappointment, loss of a loved one or other traumatic life event. This is a normal reaction and our depressed moods usually lift fairly quickly. For 10 to 15 per cent of men, and 15 to 25 per cent of women, a depressed mood can persist and become a more significant mental health problem, commonly referred to as clinical or major depression.

What is Major or Clinical Depression?

Depression is much worse than simple unhappiness. Clinical depression is a “mood disorder.” This means that a person’s emotional state is abnormally low or sad, and the person cannot independently raise his or her mood. The chief symptom of major depression is a sad, despairing mood that persists beyond two weeks and impairs a person’s performance at work, at school or in social relationships. This profoundly low mood state can be confusing because some of the symptoms of depression are behavioural, such as moving or talking slowly, while others are emotional and cognitive, such as feeling hopeless and thinking negative thoughts. This is very different from the physical symptoms of other illnesses, like the pain of a broken leg or the fever from a serious infection.

How is Depression Diagnosed?

In making a diagnosis, a doctor will ask you if you have experienced any of the

following:

• changes in appetite and weight
• sleep problems, either sleeping too much or too little
• loss of interest in work, hobbies, people; loss of feeling for family members and friends
• feelings of uselessness, hopelessness, excessive guilt
• preoccupation with failure(s) or inadequacies and a loss of self-esteem; certain thoughts that are obsessional and difficult to “turn off”
• agitation or loss of energy; if you feel so restless that you cannot keep still, or if you feel too tired and weak to do anything
• slowed thinking, forgetfulness, trouble concentrating and making decisions
• decreased sexual drive
• a tendency to cry easily, or having the urge to cry, but are unable to do so
• suicidal or occasionally homicidal thoughts, and
• at times, a loss of touch with reality, perhaps hearing voices (hallucinations) or having strange ideas (delusions).

Depressive disorders can vary in severity. A person who suffers for two weeks or more with fewer than five of the symptoms of major depression is diagnosed with minor depression.When someone suffers with five or more of these typical symptoms for at least two weeks, this is called a “major depressive episode.” For many people, however, their struggle with depression has persisted for weeks, months or even years before they visit a doctor or mental health professional. It is not uncommon for people to try to cope on their own while feeling their mood “slipping” or “dropping,” until it reaches a point that feels intolerable. People struggling with depression may also find themselves to be much more sensitive to comments from others, and they get little or no relief when loved ones and friends try to cheer them up or offer support.

The length of a depressive episode is influenced by the person’s ability or willingness to get treatment. A treated depressive episode may only last for two to six weeks; however, untreated episodes may last six to 18 months or longer. The average is about five months.

Depression and Bipolar Disorder

Depression also occurs in bipolar disorder or manic-depressive illness. Bipolar disorder is a mood disorder, but is characterized by episodes of depression, as well as episodes of mania. A person with mania will have an inflated or grandiose perception of his or her own importance or power. This can result in excessive involvement in activities that can lead to painful consequences (e.g. foolish business investments, shopping sprees, sexual indiscretions). People with mania also have less need for sleep, a pattern of very rapid speech and racing thoughts. During a manic episode, many people are unaware that their behaviour is unusual. Before a manic episode, however, people generally experience a hypomanic phase, where they exhibit some less-severe symptoms of mania (sleep disruption, a racy feeling), and are aware that they may be heading toward a full manic episode. This insight allows them to seek medical intervention and possibly avert a full-blown manic episode. While they share similar symptoms of depression, bipolar disorder and major depression are separate disorders requiring different treatment.

Different Kinds of Depression

Major depression is broken down into subtypes, each with a slightly different set of symptoms. It is important to receive an accurate diagnosis because different types of depression may respond better to different types of treatments.

Depression with Typical and Atypical Features.

In addition to the general features of depression, people with typical symptoms of depression tend to have sleep difficulties (trouble falling asleep, sleeping less than usual, and frequent waking through the night), decreased appetite, and weight loss as part of their symptoms.

People with atypical symptoms also share the general features of major depression, but they tend to struggle more with overeating and oversleeping. Evening rather than the morning tends to be the hardest part of the day. While a person with typical symptoms is generally unresponsive, atypical depression is characterized by “mood reactivity.” This means that a person will be able to respond positively to something good or a pleasurable event, such as a visit from a relative, but will quickly become depressed again when the source of this pleasure disappears. These shifts up and down can be very difficult for both the person and family members.

Seasonal Affective Disorder or Seasonal Depression

Seasonal affective disorder (SAD) is a type of depression that tends to be affected by the weather and time of the year. Symptoms usually occur during the fall and winter, and the person feels better during the spring and summer. People struggling with SAD usually experience several symptoms, including several-monthslong sad mood, increased sleep and increased appetite, characterized by carbohydrate cravings and weight gain.

SAD is more common in northern climates, where there is a significant decrease in the hours of sunlight over the winter months.While it is not unusual to experience some changes in mood during periods of decreased sunlight, people with SAD will experience much more severe symptoms, which interfere with their ability to work and relate well to others.

Post-partum Depression

While all types of depression may have multiple causes, post-partum depression follows a specific event, the birth of a child. Its onset may be related to biochemical and hormonal changes, emotional issues and social circumstances. About 13 per cent of women will experience this type of depression, which is characterized by the major symptoms of depression that persist for four weeks or more and interfere with a mother’s social and emotional functioning. Post-partum depression differs from the more common and less severe post-partum blues, which many women experience after childbirth.

Women who have had depressive episodes before pregnancy may be more vulnerable to developing a post-partum depression. Emotional issues, such as whether the baby was planned or unplanned, or whether the mother has support from the father and extended family, may also contribute to the onset of a depression. The responsibility of a new infant combined with the symptoms of depression can make this a very difficult time socially. Family and friends may wonder how the mother of a new baby could not be feeling joy on such a happy occasion. This may make the depressed new mother feel more isolated and uncomfortable in coming forward to ask for help.

Depression with Psychosis.

In some cases, depression may become so severe that a person loses touch with reality and becomes psychotic. Psychosis involves a break with reality in which a person experiences hallucinations (hearing voices or seeing people or objects that are not really there) or delusions (beliefs that have no basis in reality). Delusions may be paranoid, such as when the patient believes people are plotting against him or her. Hallucinations and delusions may be very critical or negative, and this may make the depressive state worse When a depressed patient also has psychotic symptoms, treatment involves both antidepressant and antipsychotic medications.

Dysthymia

Dysthymia, or dysthymic disorder, describes a chronically low mood with some moderate symptoms of depression, such as: poor appetite or overeating, inability to sleep or sleeping too much, low energy or fatigue, low self-esteem, poor concentration, difficulty making decisions and feelings of hopelessness. If two or more of these symptoms last for two or more years, and a person does not experience a major depressive episode during this time, then a diagnosis of dysthymia may be made. While not as severe as major depression, dysthymia can interfere with a person’s abilities at work, school or in important relationships. A person may have dysthymia, and then suffer a major depressive episode. This is known as double depression.

Personality Disorders and Depression

Sometimes, people with depression may also be told by their doctor that they have a personality disorder. What does this mean, and how does it affect the depression? Personality is what makes up the whole of the person, including thoughts, feelings, actions and relationships with others. A personality trait refers to the identifiable patterns of individuals, their usual ways of thinking and feeling, their habitual behaviours and their characteristic ways of relating to others.

A personality disorder is a statement about the quality of the person’s personality traits. It means that the person is seen to have patterns of thoughts and feelings, behaviours and relationship styles that differ in significant ways from the culture in which he or she lives. Not only do these patterns differ from the norm, but they also lead the person to feel bad about himself or herself and interfere with his or her ability to function well at work and in his or her personal life.

When a person is diagnosed with a personality disorder, a specific name is given. For example, a person diagnosed as having a paranoid personality disorder will have problems trusting others in most parts of his or her life, even when there is no basis for suspicions. This pervasive distrust complicates the treatment of depression, because it interferes with the person’s ability to develop and maintain relationships with others who might be able to provide needed support, including the doctor.

Many people have some of these personality characteristics, without any significant interference in their lives. For example, if someone is slow to trust, but is able to gain a belief in the goodwill of one or two friends or family members over time, we would think of this quality as being a personality trait, but not one that keeps the person from engaging in a satisfying life. This person would not be diagnosed as having a personality disorder.

A few examples of the many types of personality disorders are: schizoid (great difficulty attaching emotionally to others), borderline (a pattern of unstable relationships, impulsive and sometimes self-destructive behaviour), and obsessive-compulsive (perfectionist, focused on minute details, to the exclusion of others’ thoughts and opinions).

While personality disorders differ in how they manifest in each person, they all get in the way of people living comfortably with themselves or others. A person struggling with depression and a personality disorder not only needs to feel better, but also needs to learn new ways of relating to the world. This person will often be encouraged to receive pharmacotherapy and one of the talk therapies.

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