Depression can take many forms. However, if you don't know which form you have you may be treating it incorrectly. Though most people are familiar with the various depressive disorders outlined by the DSM-5 (if not, this article provides a good summary of depressive disorders across categories), however, the rigid categories of the DSM-5 doesn't adequately capture the different manifestations of depression that people experience. As such, I previously described four types of depression in a paradigm different from the DSM-5, with the hope of helping people better label the form of depression afflicting them so that they can pursue the most effective treatment. Of the four types of types I described, I've found that the trickiest to treat might be what I call existential depression.
As the name implies, existential depression is perhaps a depressive state caused by one's hopelessness, fear, or uncertainty about the existential issues we face in the human experience. It may be the type of depression that afflicted poor Hamlet in the Shakespearean play that bears his name.
What is the meaning of life? Does my life have a purpose? Does God exist? Is there some form of life after death? Are there karmic consequences to my actions? Is my suffering in this life a form of punishment by God – or is it meant to teach me important lessons about the meaning of life?
These are big questions. Do they have possible answers?
In my experience, existential depression may be common at three stages in life. The first is the angst-filled teenage-hood when adolescents reflect on their future for the first time, including their life goals and their mortality. This is often the time when they first learn in school about the atrocities of history (e.g., the Holocaust or the Rwandan civil war) and feel a sense of pessimism about humanity.
The second period may be the proverbial mid-life crisis stage when people realize that they relinquished many of their glorious dreams from adolescence simply to maintain their own survival and raise a family. The third period may be retirement, when people often struggle to find a purpose for the remainder of their lives, seeing death approaching on the horizon and fearing that their best years of life may be behind them.
Existential depression may well be the trickiest type for mental health professionals to treat because the existential questions that cause it don't have objective answers: at least not within the realm of psychiatry or psychology. Taking Prozac won’t give those with existential depression a new identity or purpose, nor will it help them to discover the meaning of life. Similarly, psychotherapy approaches that focus on concrete symptom relief are not very effective either. The possible symptoms emanating from existential depression come from a deep, nebulous source and they don’t respond much to techniques that simply address one’s cognitive errors, irrational thoughts, or lack of engagement in pleasurable activities.
In my experience, existential depression can generally require a combination of strategies, integrated over a long period of time. First, I believe that ongoing psychotherapy with a therapist who is insight-oriented (possibly from a psychodynamic/psychoanalytic orientation) is a good place to start. Therapy should not be pushed at a pace faster than the patient is willing to go, and it is not uncommon for therapy to proceed for several years without visible evidence of progress.
However, therapists should not lose faith, as therapy is secretly providing patients with the safe space necessary to explore new possibilities and identities in an environment that is validating and free of judgment and expectations. Although it might not be evident, progress is likely being made even if it didn't seem like it.
Second, exploration and participation in groups oriented towards big-picture goals (e.g., religious/spiritual groups, philosophy circles, book clubs, humanitarian organizations) can be an important adjunct to therapy, helping patients consider different life goals and purposes. Such groups enhance the feeling of connectedness, particularly if the members are aligned in a common purpose or shared belief system.
Third, I think that experiencing foreign cultures and different ways of life can be especially helpful as well. If you don't have the ability to move to a foreign country, take a pilgrimage. When it comes to pilgrimages, you may find that walking in the footsteps of those who have traveled the same path for centuries inspires a deep sense of awe, giving you perspective on your own life in the present. If that is what moves you, consider an established pilgrimage with some history behind it; like the Camino de Santiago in Spain, the Kumbh Mela in India, or the Hajj in Mecca (or, for those with more secular interests, the Burning Man Festival in Nevada).
On the other hand, you may want to create your own pilgrimage. Are you interested in seeing the seven natural wonders of the world? Or visiting every national park in the United States? Or seeing the glaciers of the Arctic before they melt? Are you willing to join the Peace Corps and experience a standard of living much different than your own? If so, you may find that there is an inverse relationship between material wealth and spiritual wealth.
Finally, regardless of whether you choose to take a physical pilgrimage, I believe it is important for those struggling with existential depression to go on an existential quest. Keep a journal of your existential and spiritual beliefs. Question your beliefs over and over and over and see how they evolve over time. Study how death is handled in different cultures. Talk with hospice nurses about their experiences. Meet with people who claim to have contact with forces outside our usual awareness, like a medium or someone that has had a near-death experience, and decide for yourself (not on what others say), about what may lie outside of your awareness. You may also want to check out the recent Netflix documentary series, Surviving Death, which covered some of these topics in greater depth, or you may want to search for books and videos that set you on a path for greater discovery.
I wish you well on your journey. Perhaps we will all meet up somewhere together, down the road.