That down-in-the-dumps feeling is something we all know from experience. When bad things are happening, nothing is more natural than to feel bad about it. But what if your mood takes a nosedive when there’s no apparent reason? Or you just can’t shake it; you’re stuck in the mud and can’t find a way out? When does a situation become a condition, a condition become a disorder?
Sadness hits all of us from time to time, but we expect to bounce back. But depression is something more prolonged, a deeper hole. Sometimes you just can’t climb back out without a helping hand. Meanwhile your life, your lifestyle, your livelihood suffer as a consequence. This is where ordinary depression crosses over into clinical depression. In the specialized terminology of psychiatry, we call it Major Depressive Disorder (MDD).
Don’t confuse this with a similar-sounding phrase: Manic-Depressive Disorder, which is the older name for what we now call Bipolar Disorder. This too is a mood disorder, but with both extreme highs and extreme lows. You can read about this here. Major Depressive Disorder, on the other hand, is all about the lows. A few other conditions may also involve low mood, but MDD is the predominant diagnosis when people come to us complaining of depressive problems. How do we identify it specifically and distinguish it from other possibilities? As with so much in psychiatry, it is about spotting its particular pattern or cluster of characteristic features.
First of all, the problem has to have been present at least a couple of weeks and be significant enough to negatively impact areas such as work and relationship, your ability to flourish and enjoy your life. The low mood may or may not feel like other kinds of sadness, such as when you lose a loved one or face serious disappointment. It can be something more subtle, sneaking up, catching you unawares. Maybe things you used to enjoy just are not fun anymore. Maybe you’re thinking what’s the point of it all. Often sleeping and eating are out of whack, in one direction or another. You eat too much and are gaining the pounds. Else you have no appetite and are losing weight. Can’t sleep. Sleep all the time. Maybe it’s tough to drag yourself out of bed to face the day; you can’t find the motivation. Could be you’re just tired or everything is moving in slow motion. Thinking clearly, making decisions is like swimming in molasses.
Like George Bailey, you may start thinking the world would be better off without you. Feelings of uselessness, worthlessness, guilt, and hopelessness, lies all, come to roost in your brain. Then there are death thoughts. Stop the world; I want to get off. Take me now, Lord; just don’t let it hurt. God forbid, sometimes someone contemplates self-harm: whether fleeting images, imagined scenarios, plans, intents. If you are reading this and have been having any thoughts of self-harm, please call for emergency help now.
Now, I’ve painted a bleak picture, all the points of darkness in an infernal constellation, but not all cases are equally dire. Even within Major Depression we further distinguish mild, moderate, and severe levels. Not all of the above criteria have to be present to qualify as MDD. Be aware, it may feel or look different than you imagined. It’s not a bad idea to see a professional about what is going on, such as a minister, a counselor or a therapist, or else your primary care provider or a psychiatric specialist. Take common-sense steps as well: fresh air, sunshine, moderate exercise, proper sleep, eating well, taking time off to relax, spending time with good friends. All these can do wonders. Then again there is medication, and this is where I come in. A bit more about these below.
So what causes Major Depressive Disorder? I really wish we knew, but we quite honestly, medical science has not nailed down this question with any certainty. We see it running in families; so heredity and/or environment likely play a role. Then there’s the explanation of a “chemical imbalance.” This is true enough, since the main way we treat it is to re-calibrate certain brain chemicals, called “neurotransmitters.” Yet this still does not answer the question of how the chemical equilibrium went tilt in the first place.
This brings us to treatment. What do we do about it. How do we bring these famous imbalanced chemicals back into proper working order? The good new is psychiatric treatment has good medications to offer. Not perfect ones, admittedly, and psychiatry is not an exact science. If only we had cut-and-dried, foolproof, objective tests, like looking at it under a microscope, identifying a bug and picking the pill that kills it. No, the reality we have to face is that we have great options to treat these conditions, but we don’t use the word “cure.” Choosing among the available medication options is frankly a bit like fitting for a pair of shoes. Yes, trust your provider’s knowledge and experience in selecting an appropriate remedy. But ultimately, you’re going to have to walk in them a while to know it the shoe fits. Everyone is an individual; you are you and not a statistic. So, if we dare mention the phrase “trial and error,” please understand you are no one’s “guinea pig.” We always aim for trial and success, and succeed we do–and it’s wonderful to behold. Only there is a process, and it can take some time, a matter of weeks, typically.
I’m mainly talking about the class of medications called “antidepressants.” In some ways this name can be misleading, since we also used antidepressants for other conditions, such as anxiety, even when depression is not present. We will go further into specifics on antidepressants in the second part of this post, but first a bit about the neurotransmitters, the brain chemicals which become “imbalanced.” What we will have to say about the different antidepressant medications will be based on which chemical or chemicals they work on.
The main brain chemical we think of in depression is called Serotonin. Call this the “sense of well being” neurotransmitter. If it’s not doing it’s job, your feeling of well-being goes off in some way, maybe in the depressive direction, maybe in the anxious direction. We have a class of medications called “Selective Serotonin Reuptake Inhibitor” (SSRI). A mouthful for sure, but suffice it to says these cause your brain’s serotonin to work harder and longer in telling you “don’t worry, be happy.” This is why use them for either depression or anxiety or both. The idea is to find that well-being sweet spot again.
A second important brain chemical is called Norepinephrine, and this one is the neurotransmitter behind motivation and attention. It’s in the adrenaline family in fact. A number of antidepressants are formulated to pack a double whammy, beefing up both Serotonin and Norepinephrine. Accordingly, these are called “Serotonin and Norepinephrine Reuptake Inhibitors” (SNRI).
The third chemical I need to mention is Dopamine. This is the “pleasure and reward” neurotransmitter. Your body rewards by boosting Dopamine when you when you take good care of yourself sleeping well, eating right, experiencing beauty, particularly listening to lovely music. Some medications are used to fine tune the Dopamine in our system and this can help restore the joy of life depression stole from us.
My hope is you’ll have something of a fuller understanding of Major Depressive Disorder after reading this brief overview of the topic. For more specifics on the medications available, I invite you to look at part two. Thanks for reading, and God bless.
A Hope & A Future Psychiatry 