Depression is characterised by a persistent feeling of sadness, emptiness, and a loss of interest in activities. Depression is a normal occasional feeling and experience. However, if depression is too frequent and or too strong, it can indicate a diagnosable condition. We can be temporarily depressed, due to recent circumstances (mild), Long Term Depressed (aka Depression Diagnosis, Depressive Episode, often just Depression) (medium), or a Diagnosis of Major Depressive Disorder [MDD] / Recurrent Depressive Disorder [RDD] (major). Depression can be secondary to other psychiatric diagnoses, such as ADHD, Autism and Bipolar, although is often recorded separately (other than Bipolar). Long Term Depression and Major Depressive Disorder are usually caused by biological factors and can be exacerbated by circumstances and lifestyle, while short term depression is generally due to life circumstances. To manage depression, it is important to establish which kind of depression a person is experiencing and its cause. Treatment can include therapy around the circumstances and life management, and if long term or major types, medication to address the underlying biological cause.

Understanding Depression

Depression is one of the few psychiatric conditions that is suitably named. If you picture your happiness, energy and desire to participate as a sliding scale, where an abundance is lifted, when you feel depressed, all of these are pushed down – depressed.

Imagine that you have caught a virus, such as the common cold. We don’t want to do things, and even if we do, it isn’t by as much as when we weren’t sick. This depression on our activities serves two purposes.

First, a large number of your body resources goes into powering up your immune system. To do this, resources are diverted away from your brain and muscles, leading to decreased cognition, a depressed mood (less enjoyment, more introspection, may be unstable aggressive mood), and muscular fatigue. Our immune system can now use those resources to combat and try to defeat the invader, preserving your life (people die from the cold viruses).

Secondly, by feeling like doing less, we free up those resources to be used and decrease the risk of spreading infection. By doing less, we allow ourselves time to heal and recuperate our lost resources. We sleep far more. By doing less, we will inherently interact with fewer people. We often feel miserable, and while we may enjoy being cared for, we do not feel like going to parties or socialising. The fewer people we see, the fewer people we infect, and the less public social resource we consume unnecessarily.

We can substitute a virus for pain and mostly the same system kicks in. It is inefficient to evolve two separate processes for repairing our bodies, so we effectively use the same mechanism for virus repair and injury repair. If you’ve ever worked on servicing a machine, it is much easier to fix it when it is turned off, than trying to repair it while it is still active. The ‘not wanting to do stuff or socialise’ is your bodies closest approach to ‘turning your body machine off’.

If our ego or emotions takes a nasty hit, our body activates the same repair mechanisms. We do less, we rest more, we heal and then we get back out there.

Temporary depression is usually a life circumstance that has occurred that we need to heal from. This could be a physical or emotional injury, an infection, loss of a job or loss of a loved one. These all cause physical and or psychic damage (to our sense of self), and need time and resources to heal.

It may seem odd that we need to heal from psychic damage (our sense of self). Who we think we are may need to be altered or adjusted due to the new circumstances or information. Our brain is a very costly organ, consuming 20% of our nutritional intake, while only weighing 2% of our body weight. Non-primate mammals generally cost their ratio of body weight to run their brain, at around 2%. Monkeys and apes take around 5% to run their brain. Bonobos and chimps, our closest primate cousins, use around 10% to run their brains. Humans cost twice as much, and most of that is to run the higher thinking functions – understanding, solving and planning. What we refer to as the executive function (which has some problems, but we are keeping it simple).

Once we have healed the damage, our normal energy states return and the depression is over.

However, not all damage can be healed. This can lead to Long Term Depression.

The neurotransmitters play a large role in managing our cognition and mood. These are a major part of why we feel like doing less, isolating and want to sleep. Even without specific damage to our body, such as immune conditions, unexplained inflammation, or Chronic Pain, we may have a psychiatric or neurological condition that triggers the same depression pattern. That may be cyclic (such as Bipolar, Seasonal Affective Disorder or PMDD) or persistent (Autism, ADHD and MDD).

Temporary Depression

Medically, we don’t consider you to be ‘Depressed’ until you have felt down for 2 continual weeks or more. Less than this length of time and we consider you that you are feeling down. The threshold is to differentiate between being a bit tired, a bit at a loss and then getting back to life again, versus perhaps we should do something about it.

Common causes for Temporary Depression is recovery from a physical damage such as an accident, infection or other generally biological medical incident; psychic injury such as the loss of a loved one, argument with a loved one, loss of a job, financial hardship, and or having to re-examine who you really are.

Psychic injury, around identity, change and loss, often overlaps with Grief. The 7 phases of grief, according to the Dr Elizabeth Kübler-Ross Model are:

1. Surprise
2. Denial
3. Bargaining *
4. Anger *
5. Sadness / Depression
6. Acceptance
7. Planning

* I change these around as I think this makes more sense and tends to track better. The Phases weren’t meant to be in any particular order, but humans tend to want them in the most common order.

When the circumstance is resolved, whether physical, psychic or both, the depression is also resolved. If you haven’t experienced significant depression before, this temporary depression can be quite an experience, often with fear of permanency and deep introspection about what life truly means to you.

Most Temporary Depression is resolved within 3-6 months, but can last up to 2 years.

If your doctor thinks that your depression or grief is complex or lasting too long, they may decide that you have long term depression.

Seasonal Affective Disorder (SAD)

Seasonal Affective Disorder (SAD) or Seasonal Depressive Disorder (SDD) is a type of recurrent depression whose timing seems tied to changing seasons. The most common form is Winter SAD, where the symptoms of depression peak in winter, on the most overcast days with the least sunlight. Winter SAD is triggered by reduced sunlight disrupting the morning circadian rhythm reset, which then effects hormones, which normally moderate our mood.

General Symptoms

Signs and symptoms of SAD may include:

• Frequent feeling listless, sad or down most of the day
• Decreased enjoyment of activities you once enjoyed
• Low energy and feeling sluggish
• Problems with sleeping too much
• Cravings, generally carbohydrate, leading to overeating and potential weight gain
• Difficulty concentrating
• Feeling hopeless, worthless or guilty
• Thoughts of not wanting to live

Winter & Autumn

Winter-Onset SAD, aka Winter Depression, may include:

• Oversleeping
• Appetite changes (generally craving carbohydrates)
• Weight gain
• Tiredness or low energy

Etiology / Cause

The basic theory for this condition is the quantity of daytime light is low / dim, which fails to reset the diurnal beginning of day during winter and autumn (fall). Your eyes have special receptors that detect the blue sky, triggered mostly by bright light, which signal your brain that this is the beginning of the day. People who are denied light, such as staying in caves, lose track of the day/night cycle and become out of sync with the standard clock. Slight patterns shift, leading to poor quality sleep, fatigue and depression.

Neurotransmitter wise, the brighter light suppresses melatonin production during the day, which increases how much serotonin is available. That is, you produce serotonin and use that while awake to manage reactivity and balance other neurotransmitters. When the lighting reaches a certain level of dimness (should be at night), your brain begins converting serotonin to melatonin. When sufficient melatonin receptors are activated by the melatonin, your brain prepares for sleep, so long as you don’t have too much adrenaline in your bloodstream. See Beating Insomnia and Beating Pre-Sleep Anxiety for more details.

Treatment

• Sleep: Improved sleep hygiene (found in Beating Insomnia) can help.
• Lighting:
  • Brighter lights in the house during winter.
  • Bring some green plants inside, or put up some green things that mimic the green of nature.
• Temperature: Being warm, but not too warm, with a continual mix of fresh air, can improve your mood.
• Medication:
  • Melatonin at night can help re-regulate your diurnal sleep system.
    • Melatonin can’t work on its own without brighter daytime lights and good sleep hygiene.
  • Some people find benefit in taking Vitamin D3.
  • Some people benefit from SSRI medication (rare) or other sleep supporting medication.
  • Talk to your GP about the above medications to see if it is suitable for you.
• Talking Therapy:
  • Addressing negative self talk.
  • Gaining support to try new approaches.

Summer & Spring

Summer-Onset SAD aka Summer Depression, may include:

• Trouble sleeping (insomnia)
• Poor appetite
• Weight loss
• Agitation or anxiety
• Increased irritability

Etiology / Cause

Summer is characterised by long days, hot nights and wearing less clothes.

Long days and hot nights can lead to impaired sleep. It is important to darken the room during sleep times, even if it is still light outside. If you are to warm / hot, you will need to look into air conditioning and active fans to try to keep your temperature down. Often, financial and environmental concerns can impact the ability to remain cool during summer and spring.

Poor sleep can lead to fatigue and depression.

People often reduce the amount of exercise they do during peak summer. A sudden decrease in exercise can affect some people’s mental health (especially ADHDers).

Image is important to most people. Two summer and spring traps for people are body image and social obligations.

Body image can be an important factor for some people struggling with Summer SAD. To manage general hot weather, many people will reduce how much clothing they wear. If you are self-conscious about your body, this may be quite triggering for you. You may find yourself struggling between choosing between being too hot or comfortable in how you appear.

Social gatherings are often popular in summer and spring, which can lead to stress about hosting or participating. Some events can have a lot of expectations around them, or the repetitive nature of weekend barbeque get togethers can become very fatiguing.

Treatment

• Sleep:
  • Improvements to temperature and lighting can help.
  • Have an afternoon nap.
  • See Beating Insomnia for more.
• Exercise:
  • While it may be prudent to reduce your exercise, don’t eliminate it. You can switch to water based exercise to help regulate temperature and fun, or do some intermittent high intensity exercise with frequent breaks.
• Social:
  • Try to not overcommit to stressful socialising, and aim for pacing yourself.
  • You don’t always have to host, nor do you have to go to every party you are invited to.
  • Pick your social connections carefully, aim for meeting with people you feel supported and understood by.
• Medication:
  • Some people benefit from SSRI medication.

[Source: Mayo Clinic – About SAD, Mayo Clinic – Treating SAD, Web MD – Tips for Summer Depression]

Long Term Depression (Depression Diagnosis)

This is the most common form of Depression that therapists and doctors deal with. This is not a psychiatric diagnosis, this is a General Practitioner Doctor diagnosis.

Once the doctor has confirmed that you have been depressed for more than 2 weeks, and that this is impacting your life, the doctor is likely to use a questionnaire such as the K10 or DASS21 to quantify that you meet the moderate to severe depression standard. The doctor will then diagnose you with “Depression”.

Depression is a persistent and consistent feeling of moroseness, being ‘down’, finding enjoyment hard, and ongoing fatigue and lethargy. While the Depression is interfering with your quality of life, it is not immediately dangerous and can be pushed through for a while. You don’t have to soldier on, you should get help. You don’t get a medal for having existed through life with depression, however if you treat your depression, you can enjoy a good quality of life.

As we age, our bodies grow, develop and change. Our brain is in and a part of our body, so it does this too. We also accumulate injuries which can have longer term consequences than a minor inconvenience, that when added together may be causing a long term imbalance. That is, Long Term Depression can spontaneously occur at some point in your life without having to have a congenital (from birth) or traumatic cause. Sometimes Long Term Depression can be caused by trauma, without nessistating PTSD (Post Traumatic Stress Disorder).

If you have ongoing Depression, you may need to take medication for a long time to get the best quality of life. This is not a bad thing. If the medication helps, then use it. That doesn’t make you weak or an addict. It means you have a medical condition. You are not weak or an addict to use Ventolin for asthma, heart medication for heart conditions, or insulin for diabetes any more than you are weak or an addict for taking antidepressants for persistent depression.

Don’t let your Depression bully you into not taking medication that helps.

Treatment

To treat Depression, you will likely be prescribed an SSRI medication (antidepressant) and recommended to see a therapist.

Medication Therapy

SSRI (Select Serotonin Reuptake Inhibitor) medication is generally very safe and can help you feel a bit better. You will be told that it will take around 6 weeks for you to feel the positive effects of the medication. You might feel the benefits within 1 to 3 days if the medication is particularly well suited to you – but if that is the case, then your depression may be secondary to a neurological condition such as ADHD.

SSRI medication isn’t the only option, and is not compatible or is ineffective with some people.

Medication that often does better:

• Sertraline (SSRI).
• Devsenlafaxine (SNRI).

Talking Therapy

Talking to a therapist can help you process your thoughts, improve your daily patterns, help you cope, help you adjust to problematic situations, and if you are responding to a trauma, treat that. CBT is generally the best talking therapy for depression.

Depression Secondary to or Comorbid

In my opinion, if you have Long Term Depression that lasts for more than 2 years, you should check to see if your depression is secondary to, or comorbid with another condition:

• Autism and or ADHD.
  • Both of these conditions can affect your neurological dopaminergic system, where you may have insufficient noradrenaline and adrenaline.
• Chronic Fatigue Syndrome, Chronic Pain, Fibromyalgia, autoimmune [read more on these]
• Cardiopulmonary condition
  • Heart and lung can cause major issues around your bodies energy system
• Food intolerance / allergy

Major Depressive Disorder (MDD)

Major Depressive Disorder is a psychiatric condition. There is specific diagnostic criteria that must be met to qualify for this diagnosis.

• MDD is also called Major Depressive Episode – MDE
  • This should be referring to an episode in a MDD, but is sometimes what people call the diagnosed condition.
• May also be called Recurrent Depressive Disorder – RDD

To be considered for MDD, the feeling of depression needs to be incapacitating and or debilitating. See the diagnostic criteria for exactly what that means (below).

Diagnostic Criteria

There are 2 major systems for diagnosing mental health. While Australia is a member of the UN and should use the WHO ICD system, Australia seems to diagnose on the United State’s DSM system.

Click to Read: DSM Diagnostic Criteria

DSM 5 TR

Five or more of the following A Criteria (at least one includes A1 or A2)

• A1 Depressed mood—indicated by subjective report or observation by others (in children and adolescents, can be irritable mood).
• A2 Loss of interest or pleasure in almost all activities—indicated by subjective report or observation by others.
• A3 Significant (more than 5 percent in a month) unintentional weight loss/gain or decrease/increase in appetite
  • (in children, failure to make expected weight gains).
• A4 Sleep disturbance (insomnia or hypersomnia).
• A5 Psychomotor changes (agitation or retardation) severe enough to be observable by others.
• A6 Tiredness, fatigue, or low energy, or decreased efficiency with which routine tasks are completed.
• A7 A sense of worthlessness or excessive, inappropriate, or delusional guilt (not merely self-reproach or guilt about being sick).
• A8 Impaired ability to think, concentrate, or make decisions—indicated by subjective report or observation by others.
• A9 Recurrent thoughts of death (not just fear of dying), suicidal ideation, or suicide attempts.

The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

The symptoms are not due to the direct physiological effects of a substance (e.g., drug abuse, a prescribed medication’s side effects) or a medical condition (e.g., hypothyroidism).

There has never been a manic episode or hypomanic episode.

MDD is not better explained by schizophrenia spectrum or other psychotic disorders.

1. The symptom must either be new or must have clearly worsened compared with the person’s pre-episode status and must persist most of the day, daily, for at least 2 weeks in a row. Exclude symptoms that are clearly due to a general medical condition, mood-incongruent delusions, or mood-incongruent hallucinations.
2. Symptom must persist most of the day, daily, for at least 2 weeks in a row, excluding A3 and A9.
3. A mixed episode is characterized by the symptoms of both a major depressive episode and a manic episode occurring almost daily for at least a 1-week period. This exclusion does not include episodes that are substance induced (e.g., caffeine) or the side effects of a medication.
4. This differentiation requires clinical judgment based on cultural norms and the individual’s history.

[Source: Nursing: Mental Health and Community Concepts [Internet]. 2nd edition, DSM-5 Changes: Implications for Child Serious Emotional Disturbance [Internet]]

Click to Read: ICD Diagnostic Criteria

ICD 10

(not released yet for ICD 11)

Understanding the ICD system

• The ICD 10 first defines a Depressive Episode, then defines Recurrent Depressive Disorder in terms of that. RDD is the ICD version of MDD.
• Inc: Includes the following.
• Excl: If these conditions exist, or better explain the symptoms, call it that (they don’t stack / can’t have both).
• F# – this is the database number for this condition.

Depressive Episode (F32)

In typical mild, moderate, or severe depressive episodes, the patient suffers from lowering of mood, reduction of energy, and decrease in activity. Capacity for enjoyment, interest, and concentration is reduced, and marked tiredness after even minimum effort is common. Sleep is usually disturbed and appetite diminished. Self-esteem and self-confidence are almost always reduced and, even in the mild form, some ideas of guilt or worthlessness are often present. The lowered mood varies little from day to day, is unresponsive to circumstances and may be accompanied by so-called “somatic” symptoms, such as loss of interest and pleasurable feelings, waking in the morning several hours before the usual time, depression worst in the morning, marked psychomotor retardation, agitation, loss of appetite, weight loss, and loss of libido. Depending upon the number and severity of the symptoms, a depressive episode may be specified as mild, moderate or severe.

Incl.:

• Single episodes of:
  • depressive reaction.
  • psychogenic depression.
  • reactive depression.

Excl.:

• Adjustment disorder (F43.2).
• Recurrent depressive disorder (F33.-).
• When associated with conduct disorders in F91.- (F92.0).

Recurrent Depressive Disorder (F33)

A disorder characterized by repeated episodes of depression as described for depressive episode (F32.-), without any history of independent episodes of mood elevation and increased energy (mania). There may, however, be brief episodes of mild mood elevation and overactivity (hypomania) immediately after a depressive episode, sometimes precipitated by antidepressant treatment. The more severe forms of recurrent depressive disorder (F33.2 and F33.3) have much in common with earlier concepts such as manic-depressive depression, melancholia, vital depression and endogenous depression. The first episode may occur at any age from childhood to old age, the onset may be either acute or insidious, and the duration varies from a few weeks to many months. The risk that a patient with recurrent depressive disorder will have an episode of mania never disappears completely, however many depressive episodes have been experienced. If such an episode does occur, the diagnosis should be changed to bipolar affective disorder (F31.-).

Incl.:

• Recurrent episodes of:
  • depressive reaction.
  • psychogenic depression.
  • reactive depression.
  • seasonal depressive disorder.

Excl.:

• Recurrent brief depressive episodes (F38.1).

[Source: ICD-10]

Bipolar Type 2

If you are diagnosed with MDD / RDD, but the regular medication treatment is ineffective, you may have your diagnosis switched to Bipolar Type 2.

In my opinion, it is misleading when psychiatrists do that. Bipolar, what used to be called manic depression, requires manic episodes as well as depressive episodes. Bipolar 2 ignores the need for mania. The depressive aspect of Bipolar refers the diagnostician to verify that the patient meets the criteria for MDD without the need for mania – so Bipolar 2 is just MDD.

Treatment

MDD is difficult to treat.

Medical Therapy

Major Depressive Disorder is primarily a biological condition. Biological problems need biological solutions.

Medication:

1. SSRI:
   • Sertraline.
   • Fluoxetine.
2. SNRI:
   • Desvenlafaxine.
   • Duloxetine.
3. TCA (if hospitalised, less useful in the community):
   • Amitriptyline
   • Nortriptyline
4. Beta Blocker, Clonidine and Melatonin:
   • At night to improve sleep.
   • If sleep is improved, daytime exhaustion is decreased, which can lead to a decrease in MDD.
   • If sleep continues to be problematic, go to a sleep clinic for further testing.
5. ADHD medications:
   • If undiagnosed ADHD, depression can be caused by adrenaline exhaustion. ADHD medications can help treat the ADHD condition, leading to less fight/flight anxiety, which leads to less exhaustion.
6. Vitamins and minierals
   • Ferritin if iron is low.
     • Supplements or infusion if dietary change is insufficient.
   • Vitamin B complex if low.
   • Vitamin C if low.
   • Vitamin D3 if not getting enough sunlight.

[Source: Major depressive disorder: Validated treatments and future challenges, Mar 2021]

Exercise:

If you do not have a heart condition or a fatigue conditions such as post viral malaise, fibromyalgia or certain autoimmune conditions etc, then regular exercise can help fend of fatigue and depression.

A correlation of reduced exercise and the onset of depression can indicate comorbid ADHD.

Diet and Nutrition:

• If iron (ferritin serum) is low:
  • Supplements or infusion if dietary change is insufficient.
• Vitamin B complex if low.
• Vitamin C if low.
• Vitamin D3 if not getting enough sunlight.
• Ensure your daily meals include a range of health and discretionary foods.

See Nutrition, Health in Body and Mind for more.

Talking Therapy

There is no magic cure for MDD through talking.

Your therapist serves two major purposes.

Firstly, they are there to help keep you going through various trials of medications, exercise, diet and other lifestyle changes to determine what is causing the low mood and energy. It is very hard to do this on your own – that’s part of the condition.

Secondly, they are there to help you learn how to challenge negative self talk and put your mind in a receptive to enjoyment state. If you do have an event that you are not processing well, your therapist can help you through that as a part of trauma counselling. MDD is rarely caused by trauma events.