What to Do If You Are Depressed: Know Your Level

A blog series guiding folks who are depressed.

Posted Jun 03, 2019

Welcome to Part IV in our “What to Do If You Are Depressed” blog series. Each day builds on what has come before. We are now aware that depression is a state of behavioral shutdown (Part I) and that we need to "face the beast" (Part II). We also are aware of the paradoxes of depression (Part III), which is that depression drives you to avoid and withdraw, but that leaves you trapped, and it sucks the effort out of you to get out. This means that we are going to need to find a path that reverses that shutdown cycle. We also introduced a new attitude, that of being curious. Today we build on that and get curious in a way that helps you understand your depression. 

Step 4. Assess your level of depression.

Let’s start by reflecting on the level of your depressive shutdown. We can do this by asking how much shutdown is present and for how long. We can think of this in terms of the intensity, duration, and frequency of the symptoms. Put in the form of questions, we can ask: How strong are the symptoms? How long do they last? How often do they occur? Probably the easiest way to get a picture of your levels of depression is to take a brief test. Here is an easy test, the PHQ 9. Please take it and see how you score, as it gives you a sense of what level of depression you are dealing with.

Note that when you take it the meaning of your scores will depend on if you are a "minimizer" or "exaggerator". This is hard to assess if you aren't trained, just know that a "minimizer" tends to dismiss or downplay their symptoms and an "exaggerator" tends to overshoot. For now, just note that the correct interpretation depends on how you tend to respond, but it should give you a basic idea. 

In addition to noting your overall severity, please take a look at the symptoms you are dealing with. These are important because they can serve as clues for areas to focus on. For example, are you having problems with sleep? If so, that might be a pattern you think about addressing, as sleep habits are key to getting the rhythms of your biology flowing smoothly. Or, if you are having trouble with negative thoughts about yourself, then a cognitive approach that focuses on adaptive thinking might be more appropriate to focus on. The second half of this series (starting with Part VII) will bring the focus more on the kinds of things you can work to change or do differently. Right now, we remain in the "awareness" stage, so just note your overall level of depressive symptoms and the more specific domains you are having problems with.  

Now let's review terms that mental health professionals use in considering this condition. This too falls under our process of “Awareness” and is consistent with the attitude of being curious. Let's start with term “clinical depression.” Perhaps you have heard of it or of “clinically significant” symptoms. "Clinical" is a professional jargon term that just refers to depressive symptoms that are causing or are associated with significant distress and difficulty functioning. It is basically a judgment call that professionals make that indicates someone is experiencing problematic or substantial symptoms of depression that could be the focus of treatment. 

Another key term is a “Major Depressive Episode” (MDE). Sometimes this is what is meant by clinical depression. An MDE is a term from the Diagnostic and Statistical Manual of Mental Disorders, which is what most professionals use as the official diagnostic codebook. An MDE is defined as the presence at least five of the nine symptoms that are listed on the PHQ 9. These symptoms need to be present most of the time for a period of at least two weeks. MDEs usually last several weeks into months.

If someone meets the criteria for an MDE, they often get diagnosed with a "Major Depressive Disorder". One key piece of information to consider is your level of severity, which is usually described in terms of "mild"; "moderate"; or "severe". Mild is where the person barely meets the criteria for an MDE. Such folks often have a "smiling depression," meaning that they can hide it from others and are not necessarily obviously depressed on the outside. That is, they can go to work and function in social settings, and don't show any motor or other gross impairments. Note that the word "mild" here is not meant to suggest that it is not important or significant. It is, after all,  part of the overall heading of a Major Depression.  

A moderate MDD is when functional impairment starts to become obvious. Folks in this category frequently stop doing things like going to work (at least miss a day here or there), reduce time hanging with friends, or disengage from life in other ways. Concentration is hard, sleeping or eating is often disrupted, and anyone who has much contact with the person would likely notice a difference in how they are presenting.

Severe levels of MDD are profound cases of shutdown. Here the person can't hide it at all. They move slowly, they talk slowly, their eating, sleeping, and pattern of functioning are often completely disrupted. It is hard to see someone in a severe MDD and not conclude they are "ill" in a medical/health sense. Sometimes you might hear this described as a "melancholic" depression (see here for a discussion of it and related terms).  

We should also make the distinction between "recurrent" and "single" episodes. As the words sound, a single episode means this is the first and only time someone has been depressed. Recurrent (or chronic-recurrent) refers to folks who are dealing with repeated episodes or folks dealing with depression for years. This distinction is important in part because it relates to prognosis. A single episode generally is easier to treat and more likely to result in folks bouncing back quickly. Why is this the case? Well, there is an old saying in neuropsychology that "neurons that fire together, wire together," and it is likely that the more time one spends in a depressive state the more that state becomes accessible. In addition, the more one has been depressed, the more vulnerable one is to relapse.

We should also be clear about the difference between “bipolar” and “unipolar” depression. Bipolar is the term that professionals use when an individual has experienced a “manic” or “hypomanic” episode in the past. These are episodes of heightened energy, positive or hyper-charged mood, a decreased need for sleep, irritability, excessive goal-oriented activity, increases in risky and impulsive behavior, and in full-blown episodes, disorganized thought, delusions, and hallucinations. The presence of bipolar disorder is crucial to know, as it requires different kinds of medications. In addition, there are good reasons to believe that bipolar disorders likely involve significant contributions from neurobiological breakdowns or malfunctions (i.e., I see bipolar conditions as more “disease-like” in its nature than unipolar). “Unipolar” are depressive conditions that do not involve a history of manic or hypomanic episodes.

Another key thing to be aware of is the notion of "persistent" or “trait-like” depressive presentations. If you recall Eeyore from Winnie the Pooh, you will be able to conjure up what it looks like when someone has persistent depressive symptoms. In the past, this was called “dysthymia” and before that, it was labeled a “depressive personality”. This tendency toward trait-like depression is related to the broader category of what professionals call “trait neuroticism.” This refers to a person’s natural tendency to experience negative emotions.

Step 4a: Assess your level of “trait neuroticism”

If one is high on the trait neuroticism then that is important to know, as it influences where one can expect to be in terms of one’s negative feelings, even when things are going reasonably well. That does not mean that you will be depressed all the time, as a depressive episode is a different state of being than just being high in trait neuroticism. But it does mean you will be more likely to experience negative emotions and have a harder time being “calm” in stressful situations than others. And, as we will see, that is very important to understand, because we will need to help you learn to relate to your feelings in a healthy way.

Here is a test you can take to see your level of trait neuroticism.

And here is a blog on trait neuroticism and how it relates to depression (and anxiety). As this blog notes, it is important to know if you are high in this trait. As we will see, learning to relate to your emotions is important and doing so can be hard if you are high on trait neuroticism. [Please, note, however, your scores on this “trait” measure will likely be higher when you are depressed than not, so if you get out of your depressive episode, it might be helpful to take the assessment again.]

Finally, I need to make a comment about what mental health professionals call “co-morbid” conditions. Co-morbid means that the individual is dealing with more than one problem or illness, and they combine to make things especially complicated. If we consider that depression is a state of behavioral shutdown, then it makes sense that it often is secondary to many other problems. And, indeed, it is highly “co-morbid” with conditions like generalized or social anxiety, personality disorders, schizophrenia, substance misuse problems, and chronic illnesses or chronic pain. Of course, all of these difficulties relate to the things in a person's life that might be driving the shutdown.

In sum, today in Part IV we focused on increasing your awareness of your depression. Specifically, we emphasized getting clear on how depressed you are by taking a screening measure, we identified some key mental health terms, and we introduced the concept of trait neuroticism and pointed to some resources for understanding that concept. This is all in the service of getting to know the beast that is depression. In Part V, we will continue the journey and start to map more clearly your personal struggle with depression—that is, we will start to map the various ways folks get depressed, which will then allow us to map who you are and put the puzzle pieces together.