Depression

Sometimes life feels like an uphill battle. Life can certainly be difficult and challenging at times. Especially  in  a  time  of  dealing  with the  post-pandemic times. 

How do you know  though if you are becoming clinically depressed? 

On this page, Hamilton psychologist Dr. Jennifer Barbera will outline how to know whether you might be clinically depressed,  what  could  cause depression  and  what  to  do  if  you  are  depressed.

The Difference Between Low Mood and Depression

Most people will experience a low mood at some point in their life. When a person’s mood changes, they may temporarily notice changes in their energy level, motivation, patience and attitude or outlook on things. For most, changes in mood are mild and short-lived. They may notice feeling different or more negative about things for hours or days. 

For approximately 8% of people, low mood becomes a more significant and longer-lasting concern.

When someone’s mood is more severely affected or becomes persistently low, this is referred to as “depression.” Although clinically speaking, there are different kinds of depression; depression generally refers to when someone experiences a marked change in their mood that persists longer than a few days. 

Along with a downturn in mood that lasts weeks, months or even years, depression involves the following concerns: 

🌱fatigue or decreased energy, 

🌱changes in appetite, 

🌱disrupted ability to concentrate,

🌱significantly increased or reduced sleeping,

🌱very low self-worth or persistent guilt, 

🌱and even thoughts about one’s death or suicide. 

How Depression is Clinically Diagnosed

When a doctor or psychologist diagnoses someone with depression, they are often referring to “Major Depression” or “Major Depressive Disorder.” 

Major Depressive Disorder” is a clinical diagnosis that indicates that a person’s mood and associated concerns have met a certain threshold of concern. The Diagnostic and Statistical Manual of Mental Disorders 5th edition is the text used to guide in the diagnosis of depressive disorders and other mental health concerns. 

According to the DSM 5, to be diagnosed with Major Depression, a person must endorse having either: 

1) a persistent low mood that lasts most of the day nearly every day for at least two weeks, 

or 2) a significant and lasting loss of interest in activities that they usually enjoyed.

The person must also experience at least 3-4 additional symptoms every day or almost every day from a list that includes: 

🌱A significant change in appetite or weight 

🌱Psychomotor agitation or retardation

🌱Insomnia or excessive sleeping

🌱Significant loss of energy 

🌱A sense of worthlessness or excessive guilt

🌱Inability to concentrate

🌱Thinking about dying or committing suicide  

For a diagnosis of Major Depression, a person must meet criteria for 5 of the above symptoms, and at least 1 of those symptoms must be persistent low mood or loss of interest in activities. 

Their symptoms must also disrupt their functioning or cause significant distress. Their symptoms must also not be better  accounted  for by another condition. 

For a visual overview of the criteria used to diagnose depression in a clinical setting, see our Major Depression Infographic.

Although a clinical diagnosis of depression is very specifically related to the above criteria, there are many other symptoms of depression that are important to consider.

For instance, people with depression may also experience: 

🌱Increased sad feelings and tearfulness, 

🌱social withdrawal, 

🌱increased pessimism, 

🌱perceptions of failure, 

🌱self-dislike and self-criticalness, 

🌱feeling numb or flat in affect, 

🌱agitation, indecisiveness, 

🌱irritability and low libido.  

Impacts of Depression

Because of the concerns mentioned, depression can be very disruptive to a person’s life and is a challenging experience for people. Aside from causing suffering, depression may also interfere with a person’s ability to work or attend  school, or other important activities, and may interfere with relationships. 

Of even more significant concern, for some people, depression can lead to self-harm or even suicide. In Canada alone, 4000 people a year die prematurely due to suicide. That means that every day, approximately 11 people in Canada take their own life.

Although suicide rates are affected by other mental health issues such as PTSD and psychosis, depression is a primary contributor to suicide. The potential impact of depression on suicide is another reason that its essential to learn everything we can about depression, its causes and how to help people overcome their symptoms. 

Causes of Depression

Depression is a complex issue because there is no single pathway that leads to depression. There are many different causes of depression. Next, we will explore potential causes of depression, but first, it’s important to know that, in essence, depression may be a symptom of a deeper underlying issue. 

What are the underlying issues that contribute to depression? Depression is thought to be caused by a combination of biological, environmental, social and individual characteristics.

Biological Influences

When someone is experiencing symptoms of depression, one of the first things that may be important to do is visit a doctor and have bloodwork. Visiting a doctor is important because there are medical conditions and vitamin deficiencies that can cause depression. 

One of the most common medical causes of depression is a thyroid imbalance. Other potential causes include heart problems, autoimmune diseases, neurological disorders, and endocrine disorders. 

Vitamin deficiencies such as B12 and vitamin D have also been noted as contributors to depression and should be ruled out with bloodwork. 

Another important biological cause of depression that should be ruled out is medications and drugs. Certain medications can cause depression or worsen depression symptoms. 

The medications that have been implicated in depression include: birth control, allergy medications, acid reflux medications, blood pressure medications, pain medication, anti-seizure medications, anxiety medications and even antidepressants. 

While antidepressant medications may be beneficial and necessary for some people, in her practice, Dr. Jennifer Barbera has seen some (but not most) people have an adverse reaction to antidepressant medication. For these select few people, their symptoms actually worsened to the point of them becoming very agitated, and they experienced suicidal ideation and self-harm. Usually, these were the same people who were reporting other side-effects such as extremely dry eyes, dizziness and nausea that lasted longer than a few weeks. These  issues  (including  SI)  remitted  after  their  dosage  was  lowered  or  the  medication  was  caused.

Aside from medications, certain drugs can contribute to depression and should also be ruled out. In particular, although many report that cannabis helps with mood or anxiety symptoms, for some people, cannabis use could contribute to or worsen low mood. Other drugs such as cocaine, steroids, ketamine, MDMA, and even alcohol have also been implicated in depression and should be ruled out.

Scientists and doctors have long thought that depression is sometimes caused or at least influenced by other biological factors such as inherited predispositions or chemical imbalances in neurotransmitters such as serotonin and dopamine. Research has also looked at the role of nerve circuits in the hippocampus in that reduced nerve activity in specific brain regions has been associated with increased rates of depression. 

Although certain neurotransmitters and reduced activity in certain brain regions have been associated with depression, the connection between brain activity and depression is complex because correlation does not mean causation. Sometimes other causes outside of the brain or body can lead to changes in brain activity, and so even though changes in the brain were identified, the original cause may have been due to individual characteristics, behavioural patterns or environmental causes.

Environmental Influences

For some people, depression can be caused by chronic prolonged exposure to stress. Stress leading to depression can occur both because of the stressful event being distressing and disruptive and also because stress leads to biological changes in the body. For instance, exposure to stress increases the release of stress hormones such as cortisol, which leads to changes in neurotransmitter activity. 

Studies have found that people who are depressed tend to have higher levels of cortisol and activation in the hypothalamic-pituitary-adrenal (HPA) axis. Environmental influences such as exposure to trauma, neglect, abuse or severe poverty can raise activity in the HPA axis. 

Also, exposure to chronic stress or trauma during childhood can lead to changes in the HPA over one’s lifetime. In essence, these changes can relate to an increased tendency for a person to go into flight or fight mode. These changes may lead to an ongoing increased vulnerability to depression for some people.

Overall, stress is considered to be a key possible contributor to depression; however, not all people respond to stress the same way. Many people can be exposed to chronic stress or even traumatic incidents and not become clinically depressed. That fact that not all people who are exposed to extreme or chronic stress become depressed indicates that other important factors are at play. 

Individual Influences

In Dr. Jennifer Barbera C. Psych’s practice over the years and across hundreds of individuals, she has consistently observed that most people who are experiencing depression symptoms also endorse a tendency to be self-critical and negative in their view of themselves. In fact, having an active inner-critic may be one of the most important contributors to depression. 

Having an active inner critic is like having an emotionally abusive person following you around for the entire day, continually criticizing and berating you for perceived shortcomings. This undoubtedly has a profound impact on a person’s mood. The influence of negative internal dialogue on depression is one reason why CBT treatment so frequently focuses on automatic thoughts and beliefs. In particular, thoughts that have a negative impact on a person’s well-being are directly worked on. 

Having an active inner critic is also associated with other mental health concerns such as different types of anxiety, particularly social anxiety, and general anxiety, substance use and some forms of PTSD. This may be one reason that depression commonly overlaps with these other disorders.

Because there is commonly an overlap between depression and other types of mood, substance and anxiety disorders, assessment is essential. In particular, it is important for people experiencing depression to have a thorough evaluation or screening for the range of mood and anxiety disorders that could be causing their depression. In fact, depression may be a secondary diagnosis to another more primary concern, such as PTSD or generalized anxiety disorder. 

Other individual characteristics are also important to explore and identify to thoroughly address a person’s depression. For instance, people with more perfectionistic traits, people who struggle with assertiveness skills, and people with avoidant characteristics may be more prone to depression symptoms. 

To illustrate, consider that a person who finds it very difficult to express and assert their needs may experience increased stress in their relationships and may have essential needs go unmet, and this can contribute to depression. Also, people who are avoidant (unwilling to make contact with uncomfortable feelings) may avoid important activities or relationships when they feel anxious or nervous. Over time this can lead to living a life away from what one truly wants or values, and this can lead to depression.

The issue of living a life that diverges from one’s values or desires raises another important individual factor to consider- the extent to which a person has experienced a gap between what they wanted in their life and what is. For instance, a person who wanted to pursue a particular career path and was, for some reason, unable, may be at increased risk of developing depression. A person who wanted a large family and has been unable may also be at an increased risk of depression. 

There are many different ways for a mismatch between hope or expectation and reality to arise. Psychologist Dr. Russ Harris refers to these mismatches as a “reality gap.” In his book “The Reality Slap,” Dr. Harris explores the many ways that people can encounter a reality gap and the ways that people respond to these gaps. 

How people respond to a reality gap has important implications for depression. For instance, as mentioned above, people who react to a reality gap with self-criticism are significantly more likely to subsequently experience negative changes in the mood that can lead to depression. 

People with inflexible personality characteristics such as perfectionism or obsessive-compulsive personality traits may also experience a more difficult adjustment to a reality gap and may become more prone to depression. People with these personality characteristics may also have more strained social relationships, which can affect proneness to depression. 

Social Influences

By nature, humans are social creatures. We have relied on social connectedness for hundreds and even thousands of years. As a result, our social lives, or lack thereof, can have a strong influence on our well-being. In this section, we will identify and explore some of the main ways that social influences can impact on proneness to depression.

Because we are such social creatures, the loss of someone important can be excruciating for people. Experiences of personal loss through a relationship breakdown or death of a loved naturally lead to feelings of grief or loss. 

For more information about the impact of relationship loss, see our coping with a break-up blog post. Whether through relationship breakdown, or death, the feelings that arise from losing someone we care about can linger for a long-time. Ongoing grief from losing someone important can lead to feelings of depression. 

How one treats themselves while they grieve a loss is especially consequential. In general, the more one allows their feelings and practices self-compassion, the less likely it is that their grief will lead to actual depression over the longer-term. When people push away their feelings, or are judgmental of themselves and the way they are reacting to the loss, the more likely it is that their grief can lead to depression.

As mentioned earlier, having an active inner critic can contribute to an increased tendency to be depressed. In Dr. Jennifer Barbera C. Psych's practice, she consistently observes that people with a more active inner critic tend to have either experienced parents that were inflexible, judgmental and/or punitive while growing up, or they experienced bullying or social rejection when they were younger. 

Bullying is also a frequent contributor to depression amongst adolescents. Bullying affects people’s self-worth by causing painful feelings of shame, embarrassment, sadness, anger and a general sense of not belonging or not being good enough to be accepted by others. These painful experiences can have a lasting impact well into adulthood. 

Aside from depression, bullying can also lead to other concerns such as reduced academic achievement, anxiety symptoms, eating disorder symptoms, increased health problems, violence and suicide. 

Bullying also leads to loneliness, which is a very painful experience. Bullying may lead a person to be inclined to avoid social connection due to fear of being hurt or rejected, thereby leading to longer-term loneliness.  

Past experiences and fear aside, because people usually prefer social connectedness, loneliness is often associated with increased depression. Not only can loneliness lead to depression, but depression tends to lead to an increased tendency for people to withdraw socially, and this can then worsen or intensify their depression. This cycle can be hard to break.

When people are depressed, they may not seek out others for social support. This is concerning because social support is known as an essential buffer against depression and other mental health concerns. People may not just avoid talking to friends or loved ones about their depression; they may also resist reaching out to professional helpers when needed. 

Approximately 49% of people affected by depression or anxiety never talk to a doctor or therapist about their difficulties. The fact that nearly half of all people affected by depression never seek help is regrettable because those people may never realize that they can overcome their difficulties with proper support and intervention. 

What People Can Do About Depression

Depression is a complex and very painful and difficult mental health issue. The good news is that there is help available, and people can recover from their depression. 

Recovering is more likely if you take these steps:

🌱The first step is identifying that you may be suffering from depression. Reading articles like this, and the websites listed below in the references section can help you determine whether you’re being affected by depression.  You  can  also  read  our  depression  blog  post.

🌱The next step would be consulting with a doctor or psychologist to have your mood assessed to verify a proper diagnosis, and to identify any contributing factors to help inform an excellent comprehensive treatment plan.

🌱If it’s been more than a year since you had an annual physical, schedule one with your family doctor to ensure you are in good health and to possibly coordinate bloodwork. Also, review any medications you are taking or any health conditions you might have that could contribute to depression.

🌱Seek out services from a psychologist or psychotherapist. A psychologist can provide an appropriate diagnosis and can also provide or coordinate effective therapy for depression. Click  here  to  contact  psychologist  Dr.  Barbera.

CBT is a commonly recommended form of treatment, which focuses on shifting negative thinking and increasing meaningful activity. Both of these interventions are very important for treating depression; however, for a more comprehensive approach, we recommend a combination of CBT and another treatment such as:

ACT, 

DBT, 

EFT, 

IFS or 

EMDR. 

Your therapist can help you decide which therapy approaches would best address the specific concerns that you have and underlying contributing causes to your depression. 

Regardless of the exact therapy approach taken, it is important to consider the following:

🌱Make sure your symptoms are fully assessed so that important variables are not overlooked. Missing significant symptoms or underlying causes can significantly lengthen the time you spend treating your symptoms. This means exploring your history, other symptoms and personality variables.

An effective therapist will also have you complete a baseline measure to more fully assess your symptoms, and to establish an objective baseline so that your progress can be measured more objectively. 

If a baseline measure isn’t being implemented, talk to your therapist or consider switching to a clinician or therapist that works directly with a psychologist and has clinical training in assessment and treating depression.

🌱Be sure to rule out other causes and/or mental health concerns such as trauma and anxiety disorders. Remember that if there is another underlying cause of your depression, then only focusing on your depression symptoms may not adequately address or resolve your symptoms. Fully resolving your depression symptoms may mean first treating another condition or concern, which could fully resolve your depression symptoms in itself.

🌱Be sure to incorporate foundational self-care into your treatment plan. Sleep, diet and exercise are pivotal to well-being, especially mood. Focusing on other areas without addressing self-care routines is like trying to build a solid house without making sure that a secure foundation is in place. 

🌱If you don’t know where to start, the quickest action you can take to start seeing results is usually to incorporate activity and exercise. Start slowly and gradually increase your exercise and activity level. 

Use a schedule to plan exercise at least 3-4 times a week (preferably vigorous exercise). 

Start with 10 minutes if needed and then gradually increase to at least 30-45 minutes.

Physical exercise is effective for depression because it leads to the production of mood-enhancing endorphin release and also leads to a feeling of accomplishment, which improves mood.

A therapist can help you decide what necessary steps to take from there. Therapy sessions can also help to work through any issues contributing to your depression. 

To book an appointment with a therapist, click here. 

If you have questions about how we might be able to help with your mood-related concerns, contact us. 

If you  would  like  to  read  more  on  depression  see  our depression  blog  post.

References:

https://cmha.ca/fast-facts-about-mental-illness

https://uhs.umich.edu/depression

https://www.health.harvard.edu/mind-and-mood/what-causes-depression

https://www.health.harvard.edu/blog/depression-common-medication-side-effect-2018071614259

https://www.drugabuse.gov/publications/health-consequences-drug-misuse/mental-health-effects

https://www.stopbullying.gov/bullying/effects

The Reality Gap, by Russ Harris. 2012

For an except of The Reality Slap visit: https://thehappinesstrap.com/upimages/The_Reality_Slap_Introduction_&_Chapters_1_and_2.pdf How