Guide to Depression Treatments
Diagnosis, Counseling, and Medication
Posted Dec 13, 2015
One of the most commonly diagnosed mental disorders is Major Depressive Disorder (also known as "Depression" and "Clinical Depression" amongst others). It is also one of the most researched and understood in terms of treatment. This article is a rough guide to the causes of depression, and most effective ways of treating it.
Depression is an experience where a person loses interest in usually pleasurable activities and has a depressed mood (very deep lack of motivation, negativity, hopelessness, and feeling empty or extremely sad) almost all day, everyday, for at least two weeks. This is paired with a variety of other symptoms that are different for each person, but include being socially withdrawn, changes in appetite and weight, changes in sleep patterns, feeling fatigued or "slowed down," feeling worthless or having extreme guilt, difficulty making decisions or processing information, thoughts of death or suicide, and being on edge or angry.
The above is distinctly different from emotions like sadness and grief because sadness and grief come and go throughout a day, whereas depression feels like a heavy and permanent blanket. People can also have hours or several days of being depressed, which is also different than Major Depressive Disorder because it does not last as long, and is usually less severe.
The level of depression is also important to note. Symptoms of mild depression are less intense, and the person may have fewer symptoms overall. People who are mildly depressed are often able to hide it from people who care about them, and can often stay functioning at work, school, and in relationships, but don't feel like themselves. Moderate depression has greater severity and number of symptoms, is usually something that other people would notice, and it starts to create larger life problems. People with severe depression are often unable to effectively function at work or school, may have very strained relationships, may stop caring for themselves altogether (stay in bed most of the day, stop bathing, stop eating, drop out of major activities, etc), and may be seriously contemplating killing themselves.
Causes of Depression
The "causes" of depression have been hotly debated over the past few decades. This will cover 4 of the most discussed theories.
Stress Exhaustion Theory
One of the theories that has been gaining support is something I call the Stress Exhaustion Theory. The basic idea is that as we go through stressful events, our bodies produce stress hormones that create wear and tear on our bodies and minds. We have to cope with the stress effectively to stay physically and emotionally healthy. When we don't cope well, or are devastated by something incredibly stressful or painful (like a massive loss), then our bodies are overwhelmed, and we emotionally and physically collapse into depression. This can also happen when we are in more chronically stressful or unhealthy situations (work, school, or relationship environments that are not good for us).
Negative Cognition Theory
Another major theory that has a lot of research support is often called Negative Cognition Theory. Basically, if someone has negative beliefs about themselves, others, and the future, and has standard ways of processing information that are negative, then the person is at risk for depression. The actual depressive episode would then emerge when the person experiences something very negative, because the interpretation of the event would usually be extreme, permanent, and hopeless.
Genetic Vulnerability & Environmental Conditions
Lots of people have heard that depression "runs in families" and mention in counseling how various family members of theirs have also been depressed. The current thinking on this is that there is likely a range of genetic vulnerability to experiencing depression. An easy way to conceptualize this is to think of how genetics works in creating vulnerability to physical injuries. For example, some people are born with greater bone size and density, and are therefore better able to withstand a level of impact without having a major injury, whereas someone born with smaller and more fragile bones may suffer a broken bone with the same impact. For depression, think of the bones as how strong your body naturally is at dealing with stress, and the impact is negative life events and stress.
Continuing with that metaphor, there are other things people can do to make themselves less vulnerable to breaking bones. One is to build up more muscle tissue. Thus people with more fragile bones could withstand a greater impact if their bones are shielded by stronger muscles. For this one, think of the muscles as a good social support system and healthy coping practices.
Chemical Imbalance Theory
A well known theory that was put into the world primarily in the 80s and 90s is related to what was described in popular culture as a "chemical imbalance." The idea came from the early success of some medications that increased the level of exposure to chemicals (known as neurotransmitters) in the brain. Researchers then began to consider that depression may be caused by deficits of those chemicals in the brain.
Since that time, and especially in the past 5 years, the Chemical Imbalance Theory has been at best seriously altered at best, and totally debunked at worst. People still in support of this recognize that it is much more complex than originally thought, and others point out that there has never been a study that demonstrates any of those chemical imbalance claims, and that evidence no longer suggests deficits are a "cause" of depression. More on this below in the "Medications" section.
There are many treatment for depression, and this will cover 4 that are the most common and most widely supported by research.
In almost everyone's experience of depression, there is a reduction in engagement in life. When this happens, we are really reducing the regular connections, tiny daily successes and pleasures, and larger meaningful activities that we need to be healthy.
Behavioral Activation is a very effective treatment that focuses on helping people re-engage in positive and healthy activities, and that the natural rewards of connecting with healthy people, having meaningful work, doing things that are pleasurable, and experiencing daily successes, will end depression. Exercising, sleeping well, and having a healthy diet are often major components of this treatments. When it is more complicated, Behavioral Activation is about helping people restructure their lives to make sure that those good things can be there, and helping to build better coping skills.
There are many approaches to treatment that focus on how people think, as a way to end depression. The main idea is that anything happening in our lives has to be mentally interpreted by us. When we interpret those events accurately, or with optimism and confidence, then our emotions about the events are different than if we interpreted the same events in a distorted form, often with pessimism or insecurity. The cognitive therapies focus on changing how we think about ourselves and the events of our lives, as a way to change how we feel. When combined with Behavioral Activation, the treatment is often called Cognitive-Behavioral Therapy.
Clinicians noticed how often depression was the result of a relationship loss or problem, and therefore started to focus treatment on the persons' relationships. One way this is done is by actually focusing on the relationship that is being built between the therapist and the client. In that relationship, the therapist is being validating, attentive, interested, and available, and offers support and care. Research has shown that for a lot of people, that relationship and the experience of the validation and care, can sometimes be enough on it's own to end depression.
Many therapists these days, including myself, blend all three of these approaches, as well as other things that may help each specific person.
There are many medications now available for depression, and the drugs have been the source of some of the widest ranging debate in all of healthcare in the past 20 years. The main issues are a) whether the medications actually work, b) why they work, and c) who should take them. This will be addressed in a future post.
Many people use a range of the treatments described above, as well as a variety of other methods. My perspective is that the first line of treatment for mild depression should be some type of therapy that blends behavioral, cognitive, and relational methods to help address the larger cause (ineffective coping, being in very stressful or unhealthy environments, negative thought processes, etc). For those moderately depressed, I recommend trying counseling for 2-4 weeks and really making a major effort with it, and then considering meds in addition to continuing counseling if things don't start to improve. For people that are severely depressed, starting medications along with counseling is worth strong consideration. Additionally, for people that are depressed due to overly stressful or unhealthy environments or relationships, and who are also unable or unwilling to make changes to those causes, medications are worth considering as a short term answer.
The great thing about the current era of treatment is that people have a lot of choices about what they want to use to help them feel better. I hope if you are reading this because you are feeling depressed, you will pick something that sounds like it would help you and get started right away. For more on how to think about depression and mental health in general, check out my Keys to Mental Health.