We all feel sad at one point or another. We can often feel better if we move around, get some exercise, or talk to a friend or family member. However, sometimes the sadness we experience can be overwhelming. Defeat, loss, bereavement, mourning, postpartum depression, family history, and even negative thoughts are all feelings that can lead to clinical depression. This article defines clinical depression and delves into some common scenarios of how depression manifests.
The textbook definition of depression includes more than just general unhappiness. According to The Diagnostic and Statistical Manual of Mental Illness (DSM-5), individuals have to meet at least five of the following criteria and for a duration of two weeks in order to be diagnosed as
clinically depressed. One of these criteria must be depressed mood and/or not being interested in those activities that one used to be interested in. These include: sleep irregularity, insomnia, feelings of guilt, lack of energy, diminished focus and concentration, increased or decreased appetite, feeling sluggish or slow and suicidal ideas. These criteria have some wiggle room. The sophisticated mental health provider must inquire into the nature and nuances of each of these criteria and how they apply to the patient because every individual person is unique and complicated. Otherwise it’s just a checklist. For example, one of the qualities of depression is increased or decreased sleep. As you can imagine, this may manifest in different ways among individuals.
Depression can be inherited. Some individuals have parents or other family members who have an overall negative outlook on life. These relatives may appear to be positive, optimistic people, but unconsciously they might think of things in a negative light or communicate with themselves in a negative way. It may not be as blatant as having a visibly depressed parent or family member that mentions their suicidal ideation on a daily basis. Sometimes it takes a very psychologically minded relative or family member to bring this to one’s attention. Most of the time it requires a mental health professional to bring it to one’s attention. This is a particularly difficult scenario because the individual going in for therapy may fall into a vicious cycle within their own mind without even realizing it. They may lose motivation to go to sleep on time or they might be late for work. They may feel completely unrested and fatigued and perform poorly at work. They may tell their friends that they have no idea why they are feeling this way. Another common example is when someone gets broken up with and ends up unconsciously believing that they are worthless and unlovable. These feelings of intense sadness may stem from family history. But they may also be learned by the individual themselves.
The thoughts one cultivates in their mind and the way they communicate with themselves both influence depression. This makes depression surprisingly common. For example, there are influencing factors known as cognitive distortions, which is just a fancy way of saying thinking error. Magnification of negative thoughts is a cognitive distortion. That is, if someone spills a drop of wine on their white pants, that person may be so critical of themselves that they deem themselves useless and clumsy and an all-around good-for-nothing. That person could be the head of their class or the director of a department. However, in this case, they are beating themselves up. They are making a mountain out of a mole hill, so to speak.
Another cognitive distortion is catastrophizing and it is happening more frequently in this COVID era. With all the uncertainty, we don’t know how things will turn out. We don’t know when some of us will return to work. We are realizing this in a piecemeal fashion. Some people might think that they will never go back to work or that they will wallow in bankruptcy. These people may begin to feel anxious and, as a result, have a greater risk of inducing a panic attack. In these moments it’s important to talk to friends or family members with good judgment. If you don’t have that please reach out to a therapist or psychiatrist. They may be able to help you gain a new perspective on your uncertain situation. During sensitive times like this, it’s easier for people to imagine the worst when none of us can see the future. This often leads to a vicious cycle of negative thoughts that would make anyone feel alone, scared, and depressed.
The environment one grows up in may contribute to their depression. For example, an individual may have very supportive and positive parents, but if the society that that person grew up in never valued that person, they could become depressed. Even though they came from a loving family, that individual could still be discriminated against for whatever reason. That could lead this individual to start communicating with themselves in a negative way. Another example of this is perceived devaluation. An individual may be loved by their parents and appreciated by their society, but perhaps it’s not as much or in the way that this individual expects. As a result, this individual perceives that they are being devalued by their peers in some way. Say someone from a privileged family or background has friends from their own privileged social circles, is very intelligent, and finds school to be very easy. This individual could still face condescension from other social circles and people of greater privilege. The individual envies to be accepted by this even more privileged social circle, and yet even though they have friends who love them and a rich quality of life, it’s not enough for them. This could become such an obsession for this individual that they begin to negatively communicate thoughts of worthlessness to themselves. If this person comes to therapy it will be a challenge. It’s a challenge because even though the therapist will try to untangle this mess within the individual’s mind, this person could have been thinking in this way for a long time. As a result, they may have a difficult time in therapy. There is a heavy burden they will have to lift that will take a while before they can overcome these self-imposed hang-ups. But it’s worth it.
Loss of a loved one often leads to depression. Certain individuals have tragically experienced death in the family. This is considered a bereavement and mourning and isn’t exactly in the category of depression. It becomes depression when the person never evolves out of their bereavement and mourning. This doesn’t happen to everyone. Child bearing is another example of this sort of depression, as carrying and delivering take a toll on a woman’s body and mind. After giving birth, a woman may experience postpartum depression. This happens for many reasons and it’s important for the mental health provider to delve into the specific situation of this new mother as to why she has become depressed. Is it because she can’t return to work? Because she doesn’t like the way she looks anymore? Is it because she feels that she isn’t ready for the new life of being a mother and taking care of this new child? These are concerns a proper psychiatrist can help to address.
Defeat and lack of success undoubtedly lead to sadness. Some individuals have been competing to the best of their ability and training for a full regular season only to have their team handedly lose to the competition. This type of loss can lead to something called adjustment disorder or adjustment reaction. Adjustment disorder is normal. We all feel sad after we lose. Adjustment disorder doesn’t always turn into a clinical depression. It only turns into clinical depression if we ruminate and perseverate on this sadness to the extent that we hold on to it in an obsessive manner. This is when something very bad happens. This type of sadness can develop some depth and personality and become especially dark. This is when it turns into clinical depression. Many people are able to come out of this adjustment disorder or postpartum depression on their own. However common, there is no shame in seeking professional guidance. You’re doing yourself a favor, and making it easier for yourself to process these feelings.
One of the darkest corners of depression is suicidal ideation. This often results from a combination of factors mentioned above. Whether the depression originated in defeat, death of a love one, perceived devaluation, or untreated trauma, any of these can lead to deep suicidal depression. But one doesn’t simply become suicidal. There is always a trail of breadcrumbs. The trouble is, those breadcrumbs don’t always readily present themselves and the depressed individual is often skilled at hiding it. One usually feels depressed for a long period of time, much longer than the two weeks mentioned above, before they attempt suicide. Whatever their specific situation may be, the individual must come to grips with what they can control versus what they cannot. They must unconsciously let go of their negative ruminations. That is the darkness that has to be released from within this individual. Whatever this person is doing to perpetuate diving into their dark rabbit hole, they have to relinquish it. This is difficult because the individual is often not conscious that they are diving deeper into that dark rabbit hole. This typically occurs when they stop visiting their therapist for whatever reason. Or perhaps they have stopped taking their medication and off their antidepressant medication. When they discard these tools, they lose the help they desperately need.
It’s particularly difficult when the individual hides this dark sadness from even their therapist. Unfortunately, this happens all the time. Sometimes the therapist may notice a melancholy in the patient’s demeanor. This may warrant the therapist to ask for a collateral contact. This is one of the requirements for medical practice. The patient must provide an emergency contact before they are accepted as a patient in a practice. This allows the provider to call a friend or family member in order to ascertain more information about the patient. This can be a life saver when the patient may tell the provider a false narrative based on their reality. Everyone has their own perception of their reality, so the provider can be misled to think that the patient is more positive than they really are. When the responsible provider has a hunch that this is happening, they may ask the patient to provide a phone number of a friend or family member. The provider is doing this to do their due diligence in fully understanding how depressed the patient is. As mentioned, there are always breadcrumbs.
People don’t get to suicidal ideation from nowhere. There is always a story. It often takes more than just a therapist or psychiatrist to help this individual out of their depression. They must surround themselves with more than one positive person. In reality, not all individuals have more
than one positive person in their life. If they don’t, they should ask their medical provider to help them find one. I can guarantee that even in the most destitute society, there are positive figures that are willing to help.
Clinical depression can be treated with skilled psychotherapy, meditation, and medication management when needed. Psychotherapy is essential for the doctor to understand exactly what you have gone through and help you foster positive thinking. Meditation is important to learn how to let go of negative ruminations and trauma that you are unconsciously holding on to. When these holistic steps aren’t sufficient, medication can be very helpful. I believe medication can be used as a tool to speed this process along, but it’s not necessarily a matter of speed. Psychologists have argued this matter ad infinitum. Coming out of a depression takes its own time. The doctor can provide guidance, but this is an individual’s psychological and emotional journey. You don’t have to isolate yourself. There is help available. Sometimes it’s important to get a reality check and have a professional guide you to think more positively.
-Arnab Datta MD