- While the modern approach to describing, diagnosing, understanding and treating depression is for the most part well organised, this approach is a relatively recent phenomenon and depression has of course been around, unchanged, for centuries. This article examines how we understand depression and how it relates to grief.
While we know that there are clear differences in how some cultures might express emotions, there are no differences in the actual emotions we feel. Zero. All of us, regardless of culture or society, are born with the same basic set, and these govern the emotional ‘flavour’ of our lives. The experiences and learning we undergo help us to modify, hide, or express our emotions but, fundamentally, we are all the same.
Sadness is one of these basic or core emotions, and depression is its extreme extension.
Some people call it profound sadness, and this obvious and prolonged sadness is one of the key features of identifying depression. One thing is certain, depression is as real a condition as influenza or a broken leg. Described variously as a “black hole”, a “deep pit”, a “thundercloud”, a “thick fog” and so on, depression is one of the most common mental disorders. Many would say that it is the most common. Certainly, it now ranks as one of the most prevalent health conditions of any kind in the western world, with point prevalence rates as high as twenty per cent. It is often called the common cold of mental illness.
Although often used indiscriminately to describe any period of feeling low or sad, depression does have clearly defined criteria for it to be correctly identified. While these seem reasonably broad they must also be taken in context. For example, because depression is such a widely used term and its key components are well-known, we can too easily apply the term indiscriminately.
By contrast, depression can easily result from other conditions (such as physical disabilities) so that its symptoms are ascribed to the other condition and we miss the correct diagnosis completely. To illustrate further, some of the symptoms of depression are not unique to depression but are shared with other conditions. We need to acknowledge the possibility of misdiagnosis, or that more than one diagnosis is possible.
As an illustration, we could easily diagnose depression when the problem is actually to do with the thyroid gland; so this possibility needs to be excluded by a doctor before the diagnosis of depression is confirmed.
What this means is that any diagnosis of depression ought not to be given lightly, but given due consideration before being applied. To be sure, most self-help books about mood would include a self-directed checklist of symptoms, as do many websites and pamphlets, but a formal diagnosis should only be made after a proper, formal evaluation by a professional clinician.
Getting the diagnosis right is critical, because as the diagnosis differs, so do the consequent treatments. Additionally, checklists and self-help books, while no doubt well-meaning, may lead us into the trap of seeing ourselves in every description, applying every situation to ourselves, and generating street-corner diagnoses which may do more harm than good. While a diagnosis is being established, certain ideas need to be understood.
There are various, in fact nine, recognised types of depression, each with particular characteristics. Of interest to us is what is properly called Major Depressive Disorder (also known as Clinical Depression) and Unipolar Depression. This could either be a single occurrence or a recurring experience. When we understand the breadth and complexity of the depressive disorders, it becomes easier to see why we need to be very careful before we apply the label of “depression”.
While we can experience depression in intensely personal ways, there are only nine key symptoms and we need five or more of them that have been obvious every day for the previous two weeks.
Two of them, depressed mood most of the day and most of the time, and loss of pleasure in most things most of the time, are so much more common than the others that we must have at least one of these two to truly have depression.
In no particular order, the other seven are: significant weight change or loss of appetite, no sleep (maybe 2–3 hours in total) or excessive sleep (even 16 hours or more) most days, extreme restlessness or obviously diminished movement, extreme tiredness or loss of energy, feeling worthless or extremely guilty most of the time, the inability to think straight, concentrate or make even simple decisions most of the time, and repeated thoughts of death and/or suicide.
These symptoms must cause obvious distress or problems in everyday life, must not be the result of a chemical we’ve taken (such as alcohol or other medication) and can’t be the result of another condition such as hypothyroidism. Lastly, and importantly, is another exclusion, and worth quoting from a medical manual – the Diagnostic and Statistical Manual of Mental Disorders.
“E. The symptoms are not better accounted for by Bereavement, ie, after the loss of a loved one, the symptoms persist for longer than two months or are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation.” (italics mine)
Depression and Grief
Depression is a mental disorder, that is to say, something is wrong. If there is a clear explanation for the depression, such as bereavement, that is to say, if we experience these things when grieving the passing of a loved one, nothing is wrong.
As we’ve already established, it is common for people to experience, among other things, sadness, pain, anger, tiredness, bouts of crying, difficulties in thinking and a depressed mood after the death of a loved one. However, it is important to learn to distinguish these normal grief responses from clinical depression. About 20% of bereaved people will subsequently develop major depression, requiring medical or professional intervention. Unpacking the subtleties of the one versus the other is the task of the clinician, but a short illustration will suffice here.
Martin sits with his family physician and describes his last two months. He outlines low or depressed mood, general fatigue and tiredness, poor sleep to the point of insomnia, loss of pleasure in things he usually enjoys, and an inability to concentrate. He says that he struggles to keep up with his job that previously stimulated and challenged him. Now though, he has trouble making even simple goals, has stopped going to cottage classes because he can’t concentrate and just wants to lie down and rest. At nights, he lies awake, tossing and turning till two or three in the morning, finally drifting into three or four hours of unrestful sleep.
From the list above, the physician would note these symptoms and the fact that they had persisted for two or more months, with five symptoms occurring during the same two week period. By all accounts, he is in the middle of a major depressive episode and goes home with a prescription for 20mg of Prozac. Officially, Martin has a mental illness, in itself nothing unusual or embarrassing, but suggesting a certain set of possible outcomes.
If the circumstances were slightly different, and Martin outlined the same symptoms but also mentioned that his wife had died about ten weeks ago, then officially Martin does not have a mental illness, given that this cluster of symptoms is a normal and expected part of the grief reaction. This would be the more likely explanation for his symptoms than the diagnosis of major depressive episode. In the main, his physician would expect him to come through these symptoms over time, with or without medication, to recover more quickly and to be less likely to suffer from major depression in the future.
Establishing the Difference
To Martin, and to the practitioner, the symptoms are qualitatively different in each case. Moreover, Martin does not have the helplessness, hopelessness, worthlessness, restriction or agitation of movement or the excessive guilt that are extremely common in people experiencing major depression. To sum up, symptoms of major depression not explained by the normal bereavement process may include:
• Continual thoughts of worthlessness or hopelessness
• Persistent inability to perform day-to-day activities successfully
• Delusions (beliefs that are not true)
• Excessive or uncontrolled crying
• Slowed physical responses and reactions
• Extreme weight loss
Those Who Help
For those of us supporting a brother or sister through bereavement, it is helpful to understand which symptoms indicate the normal depressive symptoms that are associated with grief, and those more usually associated with major depression. We are of more value when we are perhaps able to discern when to seek professional assistance.
For the bereaved though, there are risk factors that increase the likelihood of us moving from normal and expected depression associated with grief to that of a major depressive episode. Again, it is useful to have an idea of the circumstances that might contribute to the development of abnormal depression. While this is not an exhaustive list, it does highlight the most common risk factors associated with developing major depression.
• A history of depression
• A history of alcohol abuse (alcohol is itself a depressant)
• An inadequate support system
• Poor (or easily overwhelmed) coping strategies
• A feeling of being easily overwhelmed
• Other significant life stresses
In the event that we notice someone we know well suffering the symptoms of depression and assist them to seek professional help, it is helpful to understand what we could expect to be offered. In most cases our first point of contact is with our family physician.
Most physicians understand enough about depression to recognise it and ask some sensible questions. However, they can usually offer only two choices: referral (see last article) or medication. If they recognise the depression as severe then they will likely and most appropriately refer you to a psychiatrist—a physician trained in mental disorders—or ongoing support.
Many physicians prescribe antidepressants and offer frequent enough check-ups, providing that the depression is of mild to moderate severity. In these cases, the right type of counselling is as effective as medication; so there is a measure of choice. In real terms, medication is generally quicker and counselling is longer-lasting, and so the most robust option is actually a combination of the two.
In severe cases of depression, counselling is less effective and medication is the primary and most accepted approach. In most cases of this nature, a physician will defer to a psychiatrist. They may utilise a psychologist to offer specialist therapy alongside the use of medication. A psychologist cannot prescribe medication, and works at changing behaviour through other techniques, particularly by looking at how we think.
Although there is no assurance that medication will work perfectly, we can be assured that most modern antidepressants are extremely good. Unfortunately there is no great science behind which modern antidepressant to use, and so we may need to try a couple before we find the right one.
As with many medications, antidepressants merely assist the body by bolstering our stores of various chemicals. Antidepressants do not replace these chemicals, but help those we do have to work more effectively. A typical course of antidepressants would last about six months. If we are prescribed antidepressants, then as is the rule for antibiotics it is critical that we continue to take them as prescribed.
These days there is usually little risk in taking too many, but there are great risks in taking fewer than we have been prescribed, or worse, taking them erratically. Often we find that once mood has improved, people believe they are “cured” and stop their medication. Unfortunately, continually starting and stopping antidepressants decreases the overall effectiveness of the medication and makes us more susceptible to prolonged and more severe depression. In addition to medication, two other issues need a brief mention.
There are two basic forms of support networks: structural and functional. Structural supports are those people available to us as supports by virtue of the fact that they fit into our social structure. Our family is the most obvious structural support. Colleagues can be another. In a practical sense, structural supports might offer initial assistance or care, but can quickly fall away and leave one or two people who are prepared to stick with another person’s grief for the coming months. These one or two fulfil the role of functional supports.
Functional supports are what they sound like. They are those people who actually provide the function of support. They may be family members or colleagues, but can equally be professionals, friends or other people. For those suffering from bereavement and/or depression, it is crucial that they have solid functional support who can help guide them through the process.
There are things that we can all do. The most basic is that we believe that our friend does need help and, rather than try to talk them out of their problem, reassure them by being at their side to listen. This will immediately reveal that we do care and are genuinely concerned. Those who are depressed frequently feel that they are ‘beneath’ the attention of others. This is part of their feelings of diminished worth or self-deprecation.
While we haven’t space to examine coping strategies in real depth, we do need to cover some fundamental principles. While there are a million suggestions, many boil right down to only two: emotion-focused coping and problem-focused coping. Both have their place, but are useful in different ways.
Emotion-focused coping handles problems by zeroing in on the feelings and emotions that result. For example, having been given a diagnosis of heart disease, many people head into denial, which prevents the initial surge of reactions. In the first instance, this is useful as it can allow us some time to marshal our mental and physical resources. From there though, we need to become problem focused, which works to address problems, because continuing to deny the truth of heart disease will mean we fail to adjust our exercise or diet or lifestyle which will help us to survive.
When we are faced with something as potentially overwhelming as the loss of a loved one, emotion-focused coping is often the first response. This is normal and appropriate. Trouble develops a little later if we continue to use this approach when we need to use more problem focused coping.
Often it is the frustration of other people who believe this transition should have happened that leads them to say, “Pull yourself together”. What they are actually saying is that they think we should become problem focused rather than emotion focused.
As with all grief reactions, this is different for all people, and we can’t force people to move more quickly than they are able. What we can do is be aware of the difference in thinking that represents this shift, expressed in people’s actions and language, and help to facilitate it when we can.
This raises two, linked, questions, and they are: What can we do to help? and, What can the sufferer do to help themselves? That’s for next time.
So here’s the take home bit
Depression is a much-overused term, so it’s helpful to understand a little more about it. While a common part of many grief reactions, it’s not a guaranteed part, and we need to know the difference between a major depressive episode and depression as a response to grief.
Hopefully you do now! Happy to answer any questions.
Impressive words to drop into the morning coffee chat
Emotion-focused coping, Problem-focused coping
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