What is Depression?

We all feel 'blue' from time to time. Sadness is an important part of living. It helps us understand our inner world, communicate with others and gives richness and meaning to our lives. Where the 'normal' sadness that comes from the inevitable losses and frustrations of daily life, parts company with depression as an illness, is the severity, duration and the degree of disability that depression can cause.

Depression is more than a passing mood or the normal grief or bereavement most of us will feel at the loss of someone we love. Clinical or major depression is a mental disorder that occurs along a continuum from mild to life threatening. While some mild episodes of depression may resolve with time, aided by making important adjustments to daily routines and seeking out the support of others, more severe depression usually requires active treatment.

Major or clinical depression is a serious, debilitating, “whole body” illness that intensely affects how you think about things, how you feel, and ultimately how you behave. It can last for months or years and without treatment can cause permanent disability or even lead to suicide.

Depression is not a character flaw or a sign of personal weakness. It cannot be willed or wished away. People who are clinically depressed cannot simply “snap out of it” and no amount of 'pulling up your socks', true grit and determination, will lift the dark veil of depression.

Depression is a profoundly painful, distressing disorder that rarely can be overcome without external or professional help. It is an illness and it needs treatment.

Each individual experiences depression in his or her own unique manner. However, the following signs and symptoms are commonly reported and are used in making a diagnosis of depression.

• Changes in Thinking - You may experience problems with concentration and decision making. Some people report difficulty with short term memory, forgetting things all the time. Negative thoughts and thinking are characteristic of depression. Pessimism, poor self-esteem, excessive guilt, and self-criticism are all common. Some people have self-destructive thoughts during a more serious depression.
• Changes in Feelings - You may feel sad for no reason at all. Some people report that they no longer enjoy activities that they once found pleasurable. You might lack motivation, and become more apathetic. You might feel "slowed down" and tired all the time. Sometimes irritability is a problem, and you may have more difficulty controlling your temper. In the extreme, depression is characterized by feelings of helplessness and hopelessness.
• Changes in Behavior - Changes in behavior during depression are reflective of the negative emotions being experienced. You might act more apathetic, because that's how you feel. Some people do not feel comfortable with other people, so social withdrawal is common. You may experience a dramatic change in appetite, either eating more or less. Because of the chronic sadness, excessive crying is common. Some people complain about everything, and act out their anger with temper outbursts. Sexual desire may disappear, resulting in lack of sexual activity and intimacy with partners. In the extreme, people may neglect their personal appearance, even neglecting basic hygiene. Needless to say, someone who is this depressed does not do very much, so work productivity and household responsibilities suffer. Some people even have trouble getting out of bed.
• Changes in Physical Well-being - We already talked about the negative emotional feelings experienced during depression, but these are coupled with negative physical emotions as well. Chronic fatigue, despite spending more time sleeping, is common. Some people can't sleep, or don't sleep soundly. These individuals lay awake for hours, or awaken many times during the night, and stare at the ceiling. Others sleep many hours, even most of the day, although they still feel tired. Many people lose their appetite, feel slowed down by depression, and complain of many aches and pains. Others are restless, and can't sit still.

Now imagine these symptoms lasting for weeks or even months. Imagine feeling this way almost all of the time. Depression is present if you experience many of these symptoms for at least several weeks. Of course, it's not a good idea to diagnose yourself. If you think that you might be depressed, see your physician or a psychologist as soon as possible. Your primary care physician or a psychologist can assess whether you are depressed, or just under a lot of stress and feeling sad. Remember, depression is treatable. Instead of worrying about whether you are depressed, do something about it. Even if you don't feel like it right now. 

Types of Depression

Depressive disorders come in different forms. Three of the most common are Major Depression, Dysthymia, and Bipolar Disorder. Even within these types of depression there are variations in the number of symptoms, their severity, and persistence.

Major depression is manifested by a combination of symptoms (see symptom list above) that interfere with the ability to work, study, sleep, eat, and enjoy once pleasurable activities. Some people have a single episode of depression, but many have episodes that recur.

Dysthymia is a less severe type of depression that lasts a long time but involves less severe symptoms. If you suffer from dysthymia you probalby lead a normal life, but you may not be functioning well or feeling good. People with dysthymia may also experience major depressive episodes at some time in their lives.

Bipolar Disorder (also called manic-depression) is another type of depressive disorder. Bipolar disorder is thought to be less common than other depressive disorders. If you have bipolar disorder you are troubled by cycling mood swings - usually severe highs (mania) and lows (depression). The mood swings are sometimes dramatic and rapid, but usually are more gradual. When in the depressed stage, a person can have any or all of the symptoms of a depressive disorder. When in the manic stage, the individual may be overactive, overtalkative, and have a great deal of energy. Mania affects thinking, judgment, and social behavior, sometimes in ways that cause serious problems and embarrassment. A person in a manic phase may feel elated, full of grand schemes that might range from unwise business decisions to romantic sprees. Mania, left untreated, may worsen to a psychotic state, where the person is out of touch with reality.

What Causes Depression?

What causes depression? The best answer is many things. The contributing factors vary substantially from one person to the next.

To start with, biology matters— there can be genetic and neurochemical factors that play a role in the onset and course of depression. The misconception many people have, though, is that you have a neurochemical anomaly and then depression results.

In fact, it is a two-way street: Your experience influences your neurochemistry at least as much as your neurochemistry affects your experience. These include your problem-solving capabilities, your coping style (whether you deal with problems directly and proactively or either ruminate or go into avoidance), your decision-making style (many people who are either depressed or are prone to depression make bad decisions that lead to depression and even make their depression worse), your perceptions of control (whether you see yourself as a victim of life experience or as having the power to take charge of your life), the quality of your relationships and relationship skills, and many other such personal factors.

Feeling hopeless and helpless are part of the disorder, and so depressed people are prone to believe there is nothing they can do to help themselves. That is flatly untrue. When people educate themselves and take proactive and deliberate steps to get help, including self-help, the probability of overcoming depression is high.

Ignore the disempowering interpretations people give you about the meaning of your depression. Instead focus on 1) learning what your particular risk factors and vulnerabilities are and 2) then learning the strategies you'll need for skillfully managing your mood.

Even when depression eventually lifts, you will need to manage your mood with self-awareness and skill. It's a life skill everyone needs, not just those prone to depression.

Therapy can be of great help and should feature somewhere in your plans to overcome your depression. You can't effectively treat yourself when you don't know much about what you're up against.

Is Depression Hereditary or Learned?  Genetics play a mild role in major depression (a bigger role in bipolar disorder). Genetics may serve as a predisposing factor to depression, but the evidence is growing that depression has a great deal to do with the ongoing and repetitive interactions within the family.

Just as an individual has a mood, so does a family. Is the family atmosphere a serious or playful one? Emotionally close or emotionally unexpressive? Supportive or competitive? Tolerant of individual differences or rejecting of them? Problem-solving oriented or avoidant of problems?

Growing up, you have countless interactions with parents and significant others, each of which holds the potential to teach you specific skills or perspectives. If you live with perfectionistic parents, for example, you may grow up with the idea that nothing you do is right or good enough, a belief damaging to all you may attempt to do, whether in school, the job market, or relationships. It can lead to and/or maintain depression.

Interactions within the family shape your view of yourself and the world. The feedback you get in the form of peoples' reactions lets you know what's expected of you, how others see you, what you can express, even how you should manage your own body. Your self-image is largely a product of others' feedback.

Families increase or decrease vulnerability to depression in other ways, too. For example, if parents are not good problem solvers and don't actively teach skills for managing the problems of life, you can't learn effective strategies for living. Much depression today arises when people get overwhelmed by problems they just don't know how to manage.

The values parents teach, whether through word or deed, provide either a solid or shaky foundation for making decisions in life. If you learn to value money over service to others, or competition over cooperation, many choices in your life will be affected, not all of them for the better.

The bottom line is this: Your family plays a big role in your life experience, and family members can't teach you what they don't know. Instead of either passively blaming them or suffering needlessly, you must be proactive in learning your own vulnerabilities and how to manage them skillfully.

Physical changes in the body can also trigger mental health problems such as depression. Research demonstrates that stroke, heart attack, cancer, Parkinson's disease, and hormonal disorders can cause depression. The depression can contribute to the person's medical problem, as then can become apathetic and unwilling to care for their physical needs. A severe stressor such as a serious loss, difficult relationship, financial problem can also trigger a depressive episode. A combination of genetic, psychological, and environmental factors is often involved in the onset of depression.

Depression in Women

Studies suggest that women experience depression up to twice as often as men. Hormonal factors may contribute to the increased rate of depression in women; such as menstrual cycle changes, pregnancy, miscarriage, postpartum period, pre-menopause, and menopause. Women may also face unique stressors such as responsibilities both at work and home, single parenthood, and caring for children and for aging parents.

Many women are particularly vulnerable to depression after the birth of a baby. The hormonal and physical changes, as well as the added responsibility of a new life, can be factors that lead to postpartum depression in some women. Some periods of sadness are common in new mothers; but a full depressive episode is not normal and requires intervention. Treatment by a sympathetic health care provider and emotional support from friends and family are important in helping her to recover her physical and mental well-being and her ability to care for and enjoy her baby.

Depression in Men

Men are less likely to suffer from depression than women, but as many as half a million men in Canada are affected by depression. Men are less likely to admit to depression, and doctors are less likely to suspect it. More women attempt suicide, but more men actually commit suicide. After age 70, the rate of men's suicide rises, peaking after age 85.

Depression can also affect the physical health in men differently from women. One study showed that men suffer a high death rate from coronary heart disease following depression. Men's depression may be masked by alcohol or drugs, or by working excessively long hours. Rather than feeling hopeless and helpless, men may feel irritable, angry, and discouraged.

Even if a man realizes that he is depressed, he may be less willing than a woman to seek help. In the workplace, employee assistance professionals or worksite mental health programs can help men understand and accept depression as a mental health disorder that needs treatment.

Depression in the Elderly

It's not normal for elderly people to feel depressed. Most older people feel satisfied with their lives. Depression in the elderly is sometimes dismissed as a normal part of aging; causing needless suffering for the family and for the individual. Depressed elderly persons usually tell their doctor about their physical symptoms; and may be hesitant to bring up their emotions.

Some symptoms of depression in the elderly may be side effects of medication the person is taking for a physical problem, or they may be caused by a co-occurring illness. If a diagnosis of depression is made, treatment with medication and/or psychotherapy will help the depressed person return to a happier, more fulfilling life. Recent research suggests that brief psychotherapy is effective in reducing symptoms in short-term depression in older persons who are medically ill. Psychotherapy is also useful in older patients who cannot or will not take medication.

Source: Information from the National Institute of Mental Health and from professional experience in practice as a psychologist treating depressed people.

Psychotherapy as a Treatment for Depression

Psychological treatment of depression (psychotherapy) can assist the depressed individual in several ways. First, supportive counseling helps ease the pain of depression, and addresses the feelings of hopelessness that accompany depression.  Second, cognitive therapy changes the pessimistic ideas, unrealistic expectations, and overly critical self-evaluations that create depression and sustain it. Cognitive therapy helps the depressed person recognize which life problems are critical, and which are minor. It also helps him/her to develop positive life goals, and a more positive self-assessment. Third, problem solving therapy changes the areas of the person's life that are creating significant stress, and contributing to the depression. This may require behavioral therapy to develop better coping skills, or Interpersonal therapy, to assist in solving relationship problems.

At first glance, this may seem like several different therapies being used to treat depression. However, all of these interventions are used as part of a cognitive treatment approach. Some psychologists use the phrase, cognitive-behavioral therapy and others simply call this approach, cognitive therapy. In practice, both cognitive and behavioral techniques are used together. 

Once upon a time, behavior therapy did not pay any attention to cognitions, such as perceptions, evaluations or expectations. Behavior therapy only studied behavior that could be observed and measured. But, psychology is a science, studying human thoughts, emotions and behavior. Scientific research has found that perceptions, expectations, values, attitudes, personal evaluations of self and others, fears, desires, etc. are all human experiences that affect behavior. Also, our behavior, and the behavior of others, affects all of those cognitive experiences as well. Thus, cognitive and behavioral experiences are intertwined, and must be studied, changed or eliminated, as an interactive pair.

List of Cognitive Factors in Depression

Self-evaluation is a process that is ongoing. We evaluate how we are managing life tasks, and we evaluate whether we are doing what we should, saying what we should, or acting the way we should. In depression, self-evaluation is generally negative and critical. When a mistake occurs, we think, "I messed up. I'm no good at anything. It's my fault things went wrong." When someone is depressed, he/she tends to take responsibility for everything that goes wrong, and tends to give others credit for things that turn out fine. Psychologists assume that self-evaluation, in depressed individuals, is too critical, and feeds low self-esteem and a sense of failure.

Identification of Skill Deficits. Sometimes a depressed person may accurately identify a skill deficit. "I'm not good at telling people what I want from them." This is usually coupled with negative self-evaluation, "therefore, it's my fault that I didn't get what I want."  However, in depression, the person assumes that he/she cannot learn how to do what is necessary to achieve a better outcome. The depressed person believes that he/she cannot learn how to act differently. Accurate identification of social skill deficits complicates depression, because it provides a reality base for the other irrational and exaggerated negative perceptions of the depressed person.  If the skill deficit is real, then the depressed person assumes that all of the other negative self-assessments must be real too. Further, when depressed, a person is more likely to identify negative characteristics of self, and less likely to see the positive. The result is a long list of the "things I cannot do," or "tasks I'm no good at," or "mistakes I've made." Psychologists help depressed persons identify their social skill deficits, and also help them develop a plan to improve those skills. This part of cognitive therapy is more behavioral, as the psychologist teaches the depressed person how to manage their life problems better.

Evaluation of Life Experiences. When depressed, a person will focus on minor negative aspects of what was otherwise a positive life experience. For example, after a vacation at the beach, the depressed person will remember the one day it rained, rather than the six days of sunshine. If anything goes wrong, the depressed person evaluates the entire experience as a failure, or as a negative life experience. As a result, memories are almost always negative. This is reflective of unrealistic expectations.  Nothing in life ever works out just as you want. If we expect perfection, we will always be disappointed. Psychologists help you to develop realistic expectations about life, and help you determine what you need versus what you want. After all, most of the things that don't work out are little things. And even when important problems develop, we can either resolve the problem, or regroup, recover, and start again, with hope for a better future. In depression, the hope is missing.

Self-talk is a way of describing all the things we say to ourselves all day long as we confront obstacles, make decisions, and resolve problems. Self-talk is not "talking to yourself" in a literal sense, although it sometimes does involve talking out loud (depending on the person). There is a myth, that when you talk to yourself, it is a sign of "craziness" or mental illness. That idea stems from the "voices" or auditory hallucinations experienced in severe forms of mental illness, such as schizophrenia. When a person hears voices, he/she thinks it is someone else talking to them. The self-talk we are describing here is not like that at all. We all engage in self-talk. Usually, it is part of our thinking process, or what we call "stream of consciousness." As we are presented with problems, or decisions, we might think, "Okay, how do I handle this?' or "This looks like it is difficult, I better ask for help." or "I know how to fix this!"

Self-talk is not bad, or wrong, or a sign of psychological problems. It is normal. But, negative self-talk prevents us from solving problems, and can contribute to a variety of psychological problems, including depression. When faced with a problem, if our self-talk is negative, it can immobilize us. "I can't do this, I'm just going to foul it up again" or "I'll probably get fired after they see how incompetent I am." Psychologists help depressed individuals identify negative self-talk, and also teach them how to challenge these negative statements, and how to replace them with positive self-talk.

Automatic thoughts are repetitive, automatic self-statements that we always say to ourselves in certain situations. They can be positive or negative. Psychological problems develop when our automatic thoughts are consistently negative. They are automatic, because they are not the result of an analysis of the problem, they are a "knee-jerk" reaction to specific situations. For example, in social situations, do you always presume the other person dislikes you, or thinks you are stupid? When automatic thoughts control our emotional response to people, problems, and events, we ignore evidence that contradicts the automatic thought. If we cannot ignore it, we explain the evidence in terms of the automatic thought.

For example, if we talk to someone and they smile, they are really laughing at us, rather than being pleased to see us. The automatic thoughts create an expectancy of something negative. Since many things in life are vague, and can be interpreted in many ways, we learn how to negatively evaluate the world, so it agrees with our negative automatic thoughts. Psychologists help you to identify your negative automatic thoughts, and how to develop positive challenges to those negative ideas.

Irrational Ideas and Beliefs. Albert Ellis first presented the idea that irrational beliefs are at the core of most psychological problems. We could also call these beliefs unrealistic, incorrect, or maladaptive. Psychologists have also suggested that these ideas are irrational because they are not logical, or are based on false assumptions. Some examples of irrational beliefs:

     I cannot be happy unless everyone likes me.
     If I do what is expected of me, my life will be wonderful.
     Bad things don't happen to good people.
     Good things don't happen to bad people.
     In the end, bad people will always get punished.
     If I am intelligent (or work hard), I will be successful.

What makes these ideas irrational, or maladaptive, is the belief that they are always correct. Sure, working hard will increase your chances for success, but success is not guaranteed. But, there are times when we do everything right, and we still don't get what we want. For some people, this leads to the conclusion that they are lazy, no good, incompetent, or weak. The result is a loss of self-esteem, and sometimes, depression. Psychologists help you to identify your irrational ideas, and also how to evaluate which ideas are irrational and which are not. Finally, the ideas need to be changed to reflect the real world.

Overgeneralizing or Catastrophizing. Catastrophizing is a negative overgeneralization. It is "making a mountain out of a mole hill!" For example:

• One person at work does not like you, and tells you, so you know it's not mistaken judgment. You then assume no one at work likes you, or you assume that you must be a terrible person if he/she does not like you.
• You make a small mistake on a project, and assume that you will be fired when the boss finds out.
• You try your hand at a new hobby, and it does not turn out well. You conclude, "I'm  no good at anything."

We all make mistakes. If you overgeneralize one, or even a few mistakes, to the conclusion that you are bad, incompetent, or useless, you might become depressed. Psychologists help you identify and change negative overgeneralizations.

Cognitive distortions are another way of describing the irrational ideas, overgeneralizing of simple mistakes, or developing false assumptions about what other people think about us, or expect from us. We are distorting reality by the way we are evaluating a situation. The concept of cognitive distortion highlights the importance of perceptions, assumptions and judgments in coping with the world.  Psychologists help us determine what evaluations are distortions by providing objective feedback about our evaluations of the world, and by teaching us how to change the way we are perceiving problems.

Pessimistic thinking does not cause depression, but it appears to be easier to become depressed if you tend to view the world with considerable pessimism. After all, pessimism is a tendency to think that things won't work out as you wish, that you won't get what you want. Pessimism feeds the negative cognitive distortions and self-talk. On the other hand, optimism appears to create some protection from depression.

Hopelessness is a central feature of depression, along with helplessness. If you view your world as bad, filled with problems, and don't think you can do anything about the problems, you will feel helpless. If you don't believe your life will improve, if you think the future is bleak, then you will begin to feel hopeless. Pessimism encourages these negative assessments of your life.  Optimism prevents you from reaching those conclusions. In fact, psychologists have researched ways to learn how to be more optimistic, as a way of fighting depression. 

Summary of Cognitive Psychotherapy Approach

First, remember that we cannot present cognitive psychotherapy in one web page, or in a few paragraphs.  But, the essence of cognitive therapy is the assumption that irrational thoughts and beliefs, overgeneralization of negative events, a pessimistic outlook on life, a tendency to focus on problems and failures, and negative self assessment, as well as other cognitive distortions, promote the development of psychological problems, especially depression.  Psychologists use cognitive therapy to help you identify and understand how these cognitive distortions affect your life. Cognitive therapy helps you to change, so that these issues will not rule your life.  If you are feeling overburdened, that life is not working for you, and you don't know what to do next, talk to someone who can help, consult a psychologist.

Efficacy of Cognitive-Behavioral Therapy
as a Treatment for Depression

Several meta-analyses have been conducted over the years to determine the clinical efficacy of cognitive-behavioral therapy in the treatment of depression as compared to no treatment, pharmacotherapy, and other forms of psychotherapies as well as the relative efficacy of the pure cognitive and behavioral components individually.

All meta-analyses found evidence of a clear superiority of cognitive behavioral therapy over “no treatment” or “wait-list” control conditions. Six of nine studies found significantly greater treatment effects for cognitive therapy as compared to other forms of psychotherapy. Of the six studies directly comparing cognitive therapies to behavioral therapies, cognitive therapy outperformed behavioral therapy in three studies and was comparable to behavior therapy in three studies. Finally, cognitive therapy outperformed medication in all five meta-analyses comparing the two.

Taken as a whole these meta-analyses provide substantial evidence that cognitive-behavioral therapy is an effective treatment for depression; at least as effective as medication.  

The high degree of relapse (i.e., a continuation of the index episode of depression before recovery) or recurrence (i.e., a new episode of depression after recovery) in depression has made the issue of maintenance of treatment success a critical one for both psychotherapy and pharmacotherapy. Without additional treatment, the range of relapse appears to vary between 50% and 80% within the first year of recovery from depression. Medication studies estimate that symptom relapse or recurrence tends to occur within 6-24 months after treatment is discontinued.

Cognitive-behavioral therapy has generally been associated with a lower rate of relapse than patients treated with medications alone. Although the methodology of studies varies, meta-analysis of cognitive-behavioral treatment studies has generally reported 0%-50% relapse rates within 1-2 years after treatment ends.

Source: Weissman, M.M. (Ed.) (1999). Treatment of Depression: Bridging the 21^st Century. (pp.264-274). New York, NY: APA Press.