Depressive Disorders

It is not abnormal to become depressed, but not having the ability to undo this depression is abnormal. There are a number of different types of depression; some are genetic in origin and psychological factors such as an individual’s personality and lifestyle only play a small role in this type of depression. Whereas other types of depression are closely linked with our life experiences and can be fully understood in terms of the stress that we experience on a daily basis. However, in most cases, both genetic and environmental factors play important roles.

It has been reported that women and men at some time in their lives experience clinical depression and it’s on the rise globally. It seems as if the advancement of modern science and the comforts of modern day living haven’t reached the deeper reaches of the human mind and reduced our overall suffering. On the contrary, technology has been blamed for taking us away from ourselves. It is strange that at school we are taught many subjects but not one that can help us manage our moods more efficiently.

Defining depression

Depressed mood, loss of interest and enjoyment, and increased fatigue are the most typical symptoms of depression. The other symptoms of depression are:

  1. Reduced concentration and attention
  2. Reduced self-esteem and self confidence
  3. Ideas of guilt and unworthiness
  4. Bleak and pessimistic views of the future
  5. Ideas or acts of self-harm or suicide
  6. Disturbed sleep
  7. Diminished appetite

For a definite diagnosis at least two of the above symptoms should be present for at least two weeks without remission and be severe enough to cause impairment in daily activities. At times, depression occurs in the form of distinct episodes with full recovery and is associated with periods of elevation of mood, increased energy and activity. This type of depression is classified as bipolar affective disorder or manic depressive disorder. It is not uncommon to see patients who present with a mixture of anxiety and depressive symptoms and this disorder is referred to as mixed anxiety and depressive disorder.

Other types of depression

Adjustment disorders: depression resulting from normal life stresses that the individual finds difficult to cope with has been described as adjustment disorder with depressive reaction. The symptoms in this disorder are circumscribed around stressful life events. They disappear when stress disappears and reappear when stress reappears.

Bereavement reaction: bereavement reaction is considered abnormal requiring treatment if it lasts longer than six months or it presents with unexpected symptoms such as psychosis or denial of death.

Substance induced depression: Individuals suffering from an alcohol problem and drug addiction are more likely to suffer from depressive episodes.

Secondary depression: depression that occurs in response to having a serious physical (cancer, epilepsy, parkinsonism etc) or mental illness (schizophrenia, OCD etc) is described as secondary depression. It is a justified response to having a major illness. Fortunately the secondary depression responds to treatment as well as the primary one.

Understanding Depression: It is difficult to distinguish clinical depression from normal sadness apart from it’s consequences and impact on the life of the individual, which may well be a reflection on the individual’s ability to cope, rather than on the nature of the problem. In simple terms, depression becomes clinical when it causes significant distress and interference with our everyday life and it can’t be shaken off. It assumes certain characteristics of a clinical state characterised by loss of appetite, loss of weight, loss of pleasure or motivation to do anything.

A basic human condition: Soren Kierkegaard (1849) reminded us that all normal human beings are at the very bottom of their existence – anxious, depressed and insecure. He said that in our normal consciousness we are unable to notice these deeper feelings. In this regard depression can be seen as a natural emotion if it happens as a result of this awareness of the deeper self. It is only natural to feel small and helpless in this ever growing world in which we seem to have very little control over things. The sheer number of people inhabiting this planet and their suffering fills us with a sense of helplessness. It may be that the feelings of helplessness described by patients are just a disguised manifestation of this existential anguish and powerlessness which the individual finds difficult to accept.

Paul Tillich (1952) explains it further by saying that the depressed person is more sensitive to these problems related to being a human being, and so feels pfound emotions. Being unable to confront these emotions, they settle into a limited self-affirmation and restricted life style. Their avoidance of this pain leads to a restriction of the joys that could be available to them. Depression has been viewed here as a consequence of the individual’s inability to come to terms with the unavoidable human pain. One can say that one third of the human suffering is unavoidable (ontological) and the remaining two thirds (ontic) are there because one cannot accept the unavoidable one third, and is trying hard to get it out of one’s life.

Absence of Meaning: Depression can be seen as a result of our inability to discover or create meaning in our lives, or our failure to come to terms with the feelings of meaninglessness that we normally encounter at times. There are no blueprints for human life, no grand designs or maps that we can follow. We are free to become what we want to and create
meanings through our actions and choices.

Psychiatrists generally see a sense of meaninglessness as a manifestation of depression whereas in existentialism (a branch of philosophy) it is understood as the cause of it. In an existential sense, meaning is seen as a by-product of one’s engagement with this world and a failure to engage with the world could result in depression. This is of course a simplistic explanation of meaning – Heidegger saw the crisis of meaning as unavoidable to some extent. He understood human beings as constantly being caught between the two positions of ‘no longer’ and ‘not yet’ which can lead to a loss of meaning as whatever we have achved becomes ‘no longer’ taking away all the meanings with it. We know that different things matter to us at different times but the fact that they do not hang together as some unified whole takes away their meaning.

An Alienation from Oneself: Heidegger has pointed out that the alienating influence of technology may be related to the phenomenon of rising depression in modern society. The remedy lies in ‘return to our true nature’ and staying connected with our inner world.

Increasing globalisation of culture and migration have posed unique problems for the mental health professional. It does not seem to be producing cultural uniformity; rather it has resulted in feelings of confusion, isolation, loneliness and identity problems which may be the additional factors contributing to the rise of depression. More and more people are being uprooted from their homeland as a result of migration and are leading a life of relative social isolation with a limited support system. From an existential perspective, it can be seen as an advantage as it offers opportunities to confront the basic human concerns. Without this work one remains vulnerable to depression. Todres (2002), in his article, has pointed out that religion, family and community life seem inadequate in addressing this task in recent times.

A Medicalised Social Malady: It has been argued and with good reasons that to some extent we have medicalised unhappiness. Depression in this context can be seen as a social
problem as it is closely linked with poor social support, family burden, poverty, divorce, drug abuse, urbanisation, modernisation etc.

Society, Culture and Depression: Information technology has vastly increased the awareness of an average citizen about things happening elsewhere, and as a result has increased the gap between ‘what is’ and ‘what should be’ in the outside world, and the internal tensions between ‘who-I-am’ & ‘who-I-think-I-ought-to-be’. Cultural factors play an important role in the causation of depression. When a group of American psychologists met with the Dalai Lama, he asked what difficulties are most common for Americans. One of the most mentioned and strongest was self-hatred and low self-esteem. The Dalai Lama’s reaction was incredulous, for self-hatred and low-self esteem are unknown in Tibetan Culture (Kornfield, 2000).

Women and Depression: Women are twice as likely to suffer from depression as men. Feminists have argued that to a large extent depression is not rooted in the biology, and that the altered biology (reported in the lietrature) may be a concomitant of social, political and cultural forces operating in a given society. Women tend to seek help more often than men.

Why do we become depressed?

It is not difficult to understand the general causes of depression but what is more important is to understand ones own specific causes.

The general factors could be:

Losses of all kinds: losing a parent in childhood has been associated with high rates of depression later in life. At times it is just a fear of loss or a symbolic stress that reminds us of past experiences of losses that brings on depression.

Having no attachment figures in childhood and frequent separations in adulthood. A history of having a disturbed relationship with one’s own mother/ attachment figures in infancy and early childhood is known to cause depression later on in life.

Problems in parenting such as high parental expectations and internalisation of those high expectations can cause depression. Secondly, being brought up in controlling environments and suffering from parental neglect can cause depression.

Adopting very high internal standards such as – to be good and loving, superior and strong, and to be loved and worthy all the time can cause depression.

Inability to give up unattainable goals can cause depression. In relationships it could be related to one’s failure to elicit specific responses from specific people. The situation gets
complicated when the alternatives to the expected response or behaviour are not acceptable to the individual.

Depression can occur when a positive action does not bring about positive results. It is seen when the social environment does not provide sufficient rewards. One can argue against this position by saying that depression can result when one hasn’t learnt the behaviour that could be suitably rewarded by others. Some investigators consider depression as a result of ones own inability to reward oneself.

In relationships depression can occur as a result of problems in distance regulation. The distance between two individuals should be optimal, like the strings of a guitar. Being too close or too far apart will not produce good music.

Depression can cause disruption in ones daily rhythms – not eating enough and in time, irregular sleep-wake cycle, reduced physical activity etc. All this can make depression worse.

Depressed individuals tend to withdraw from the outside world and other human beings which results in a worsening of their depression. Increasing human contact and being more engaged with the outside world can be therapeutic..

Treatment of Depressive Disorders

There are two broad categories of treatment employed in the management of depression: psychological approaches and biological treatment that includes drug treatments.

Drugs treatment: there are about half a dozen anti-depressant drugs that are commonly used in treating depressive disorders. These drugs act on different chemicals in the brain. Different individuals respond to different categories of drugs hence it is important to try more than one drug if the response to the first drug is not satisfactory. These drugs either selectively act on serotonin and noradrenaline levels or on both these chemicals.

Psychological treatment: the commonly used psychotherapies in depression are cognitive behavioural therapy, interpersonal therapy, psychodynamic therapies and existential therapy.

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