Depression: 
Causes, Symptoms, and Treatment 

by Joseph M. Carver, Ph.D., Psychologist

Introduction:

Depression is perhaps the most common of all mental health problems, currently felt to affect one in every four adults to some degree. Depression is a problem with mood/feeling in which the mood is described as sad, feeling down in the dumps, being blue, or feeling low. While the depressed mood is present, evidence is also present which reflects the neurochemical or "brain chemistry" aspects of depression with the depressed individual experiencing poor concentration/attention, loss of energy, accelerated thought/worry, sleep/appetite disturbance, and other physical manifestations. When this diagnosis is present, the individual will exhibit at least five of the following symptoms during the depressive periods:

• - Depressed mood, most of the day or every day
• - Markedly diminished interest in all or almost all activities
• - Significant weight loss or gain or appetite disturbance
• - Insomnia or excessive sleeping
• - Psychomotor agitation or retardation (restlessness)
• - Low energy level or chronic tiredness
• - Feelings of inadequacy, loss of self-esteem, and/or self-deprecation
• - Decreased attention, concentration, or ability to think clearly
• - Recurrent thoughts of death or suicide, an expressed desire to be dead

Causes of Depression:

Depression can occur under many circumstances but most commonly is present in these two situations:

Sudden Severe Loss In this situation, the individual has experienced a sudden, perhaps surprising severe loss. This loss may be the death of a loved one, loss of a job, loss of friendship, or other grief process. In this type of depression, the patient can clearly identify what is creating the depressed mood.

Long-term High Stress Level In this situation, the patient is depressed but can't quite put their finger on the cause, the "I'm depressed but I don't know why" condition. Imagine running a video tape of your life, reviewing the past 18 months. Look at the stress you've been under, the amount of responsibility, the number of pressures, and the number of hassles. In actual clinical practice, this cause of depression is seen more often than sudden loss. This type of depression creeps up on you. When this type of depression is experienced, the patient offers comments such as: "I don't know what's wrong!" "I don't know how I feel." "My feelings are numb."

Brain Chemistry and Depression:

The human brain operates, much like your automobile, on fluids called neurotransmitters. Just as your automobile has brake fluid, antifreeze, transmission fluid, and oil - your brain runs on these neurotransmitters. Some give us energy, like those related to adrenalin, some control body movements ("dopamine" as an example), and some control mood.

The brain neurotransmitter often associated with depression is called serotonin. Serotonin is the brain's "oil", a rather slow-acting neurotransmitter that is associated with sleep, appetite, energy, alertness, and mood - just to name a few. Using the automobile as an example, if we drive our car to California at a speed of 120 mile per hour, running the engine hot for a long time, it would obviously use more oil. As long as we provided gas, however, it would continue to run. Now suppose in our trip that for every two quarts of oil we burn, we only replace one quart. By the time we reached California we'd be several quarts low and our engine would be obviously overworked and overheated.

During long-term high stress, the brain burns its' oil, serotonin, at a higher rate. The bottom line in depression and stress: The brain burns up more serotonin than it can replace! In the end result, after many months of severe stress, the brain is using serotonin faster than it can create/replace it. Your neurochemical level of serotonin drops and you become depressed.

You'll know your Serotonin level is low (and depression is here) by the following symptoms:

1. Most depressed folks experience early morning awakening, usually around 4:00 am (farmers are exempted). Serotonin, you see, controls our sleep cycle.

2. Concentration and attention will drop. Depressed children/students will experience a drop in grades. You'll start putting odd things in the refrigerator (a bowling ball is the office record!), forget why you went to the grocery, and become very forgetful and scatterbrained at work/home.

3. You'll lose physical energy. You can sleep for ten hours and you'll still be bone tired. You will cry at the drop of a hat - driving down the highway, doing dishes, sitting at work, etc.

4. Sexual interest, appetite, and general interest will rapidly drop. You will stop answering the phone, stop visiting friends/relatives, and pull the blinds.

5. Most dangerous - your mind speed will increase. Your mind will race at what seems like 200 miles per hour. Depressed people often tell their doctor "I can't get my mind to stop!" The minute you wake up in the morning - it will start up. Your brain will then turn against you. It will reach in your memory and pull out every bad memory it can find - abuse as a child, failed relationships, etc. - anything to make you feel bad and especially guilty. You will be tortured by your own thoughts.

6. As your mind speed picks up, the "garbage truck" will arrive. While the brain is already torturing you with the past, it will create/invent new ideas/thoughts to torture you. In every case of depression, if the depression stays long enough, you will receive the same "garbage" thoughts from your mind. You will be told:

- you are a burden to your family/friends

- you have failed/disappointed your family

- no one really cares about you

- your children would be better raised by someone else

- your family would be better off without you

- your spouse would be better off without you

- you are going crazy and there's no hope

- it would be better if you weren't around

- you would be better off dead

- you should probably kill yourself

If you're depressed - then you already know about the garbage truck. It's almost impossible to explain this part, and the excessive mind speed, to someone who has never been seriously depressed. If your depression goes untreated, this constant "garbage" will totally destroy your self-confidence. Try as you may, you will be unable to control this part of depression.

7. As part of the "garbage truck", your mind will try to make you as uncomfortable as possible. You may be flooded with thoughts of violence (against yourself and others), you'll think you are condemned by God, or you'll think you deserve this condition for some reason. Your garbage will also tell you that if you seek professional help (physician, psychologist, psychiatrist, etc.) that you'll be committed to an institution forever.

8. When depressed, your brain begins running a mental "video tape" of your worst hits/experiences. If married, a mental tape of the marriage is played daily, only focusing on the worst experiences. If you are young, you will suddenly become preoccupied with your upbringing, who got the best gym shoes, the favorite child, the car you never received. Frequent if not constant thoughts and preoccupations about past problems and issues is a common sign of depression.

In short, depression is a neurochemical reaction to severe and prolonged stress, either suddenly surfacing or gradually creeping up on you over a period of many months. The treatment for this dark cloud is much easier than you think.

Current Treatment for Depression:

Treatment for depression frequently involves two programs, one using antidepressant medication and the other repairing the damage done by months of "garbage". In all current research, the best way to recover from a severe depression is using both methods.

Medication Treatment: Remember the automobile example, being several quarts low after running too hot for too long. Depression is treated medically in a similar manner - we add a few quarts of oil until the fluid level (Serotonin) is normal. In depression, we use antidepressant medication to "add" the brain's oil, in most cases, Serotonin. An antidepressant medication slowly increases the Serotonin in the brain. Prozac, Zoloft, and the newest "Paxil" are antidepressants especially made for this purpose. They form a new class of antidepressant medications, SSRI's, or (ready for this?) Selective Serotonin Reuptake Inhibitors (SSRI).

As in the automobile, as your "oil" level goes up, your symptoms go down. Most antidepressant medications require at least four to six weeks to increase the serotonin level significantly although you'll notice improvements after the first week. Antidepressant medications, the SSRI's for example, often stop crying spells in five to seven days and stop the "garbage truck" in five to ten days.

Psychological Treatment: Psychologists and other therapists work with you to repair the damage done by the "garbage", helping you sort out reality from what your brain has fed you over the past many months. Many people feel going to a psychologist or therapist involves laying on a couch and talking about your toilet training during childhood - Nonsense! Modern psychologists are experts in not only brain chemistry, but how to repair "thinking" damage and rebuild/reconstruct your confidence. The combination of medication and therapy is extremely effective.

Usually, successful treatment for severe depression involves both medication and therapy/counseling. With both, you can expect normal sleep to return first, followed by a slowing of mind speed and the garbage truck leaving.

Some General Thoughts:

1. Depression is the most common mental health problem treated by modern psychologists and psychiatrists. In most cases, hospitalization is not required unless you have waited until you have active suicidal thoughts.

2. If you are depressed, expect your brain to be filled with mental garbage - get ready for it! During this time, do not take action on those garbage thoughts and make no major changes in your life. It's best to wait until the garbage truck leaves before making decisions that will or may change our life.

3. Depression has been researched by physicians, psychologists, psychiatrists, scientists, and others. Listen to the advice of your professionals who study depression - not your neighbors or your aunt Gladys. If placed on medication, you may be told "Don't take that Dope!". Remember, the people giving you advice don't have a 200 mile-per-hour garbage truck following them! Stick with professional opinion. Depression is a chemical problem, not caused by demons, devils, poor eating habits, a new moon, or other old-wives tales.

4. You may have other symptoms with your depression, such as severe anxiety or agitation (pacing, no sleep at all, "hyper", etc.). That only means another neurochemical has kicked in. In these cases, a psychiatrist can best select the medication for the combination of anxiety and depression.

5. When you are depressed, those who love you will become a pain-in-the-butt. They will "bug" you constantly, trying to cheer you up, giving you advice ("snap out of it" is most common), and trying to be by your side. Children will become shadows when their mother is depressed, almost protecting Mom. Be prepared for this.

6. During depression, remember that your brain goes on a bad-memory hunt, looking for old memories to torture you. Be prepared to relive or re-feel old hurts, old doubts, old guilt, and old sorrows. Be curious about what memory files the brain selects rather than focus on those memories. You can expect your brain to constantly replay the video tape (your "worst hits" tape) of your life. You'll feel guilty for things you did as a child, mistakes you made ten years ago, etc. You'll live in the past as long as the depression remains. It may interest you to know that as the serotonin level increases, the "past" returns to the past as a memory - not a torture.

7. As your brain tortures you, it may "lock on" horrible thoughts. You may feel you have a terminal disease. You may become preoccupied with guns, evil thoughts, etc. Often, individuals feel they are somehow contaminated by a killer disease, fearing they will pass it to their family. One husband brought his wife in for treatment when she began fixing breakfast in a surgical mask and rubber gloves! One man sought treatment at the office after nailing his closet door shut with 148 nails - his brain became preoccupied with the shotgun in that closet, telling him to kill his family and then himself.

In other depressed situations, people become obsessed with other issues, almost always "the road not taken". Often viewed as mid-life crisis, a straight-laced businessman now wants a Harley and a tattoo while another individual begins suddenly thinking about a past sweetheart. In almost all of these situations, the individual acts totally out of character.

8. All depressed folks look for escapes. Common methods of trying to escape depression are excessive alcohol use, drugs, sexual relationships, changing jobs, etc. A lot of good marriages are lost during these times as the spouse of the depressed partner hears "I've got to have space" or "I've got to get away and find myself!" You'll find these escapes don't work. These methods only complicate your depression and your recovery. Best bet - don't make changes, just get to a professional.

9. Most people classify all medications that act on emotions as "nerve pills". This is far from the truth. Psychiatrists actually have medications for anxiety/nervousness (Valium, Ativan, Xanax, etc.) and those for depression (Elavil, Prozac, Zoloft, Sinequan, etc.). Different brain chemicals are involved in each condition and many people make the serious mistake of taking an antianxiety medication for their "nerves", thinking they are treating their depression - Wrong! While you will be calmer, you will stay depressed. It's like drinking six beers for a broken arm - you might feel the pain less but your arm is still broken. A psychiatrist is most qualified to select the proper medication for your condition.

10. If you are placed on medication, don't expect an immediate recovery. With antidepressants, it's similar to refilling the oil in the car, only at 1/8th of a quart a day. As you continue to take the medication, your mood will slowly improve as the serotonin level increases in the brain. When depressed, every day is bad and full of mental garbage. As medication continues, you'll have a bad, then good day. As serotonin gets higher, you'll have a bad morning, then three good days. In short, it's bad-and-good at first, then finally good days with routine hassles. No one is happy all the time. People that are happy all the time are institutionalized - it's not normal. "Normal" is a good mood with normal reactions to the stress of everyday life.

11. In selecting a therapist/counselor, each one is different. All have different personalities, styles, and attitudes. Select one that has your style and most important - somebody that makes sense. If you meet one that says "I don't believe in medications" - get out of there! That therapist is about thirty years behind modern treatment. Often, your family physician is in a position to recommend the best therapist in your area. You can also look for signs of acceptance in the professional community, such as hospital privileges. You may have to shop around to find a therapist right for you.

As a word of caution, many inexperienced therapists or those with limited training may miss the fact that you are depressed. You may arrive at the therapist office preoccupied about something in your childhood that actually happened 20 years ago. You may also fool your family physician with multiple physical complaints as when Serotonin is low, all body systems seem to go haywire. A properly trained therapist will not only asked about your life and upbringing, but about the physical aspects of your situation; your sleep, sexual interest, concentration, and other indicators of low-serotonin depression or stress. The inexperienced therapist might focus on the "garbage truck" thoughts and miss the big picture, the presence of depression. If you are clinically depressed, weekly discussions of your past as told by the garbage truck will only prolong your depression and possibly intensify it. If in doubt, consult your family physician to obtain a medical/physical view of the situation as most physicians are usually trained to recognize the indications of low-serotonin depression. If you think depression is part of the problem, ask your family physician to refer you to a psychiatrist or psychologist in your area.

12. Depression affects more than the individual with the depression - it's a family-and-friends problem as well. If your spouse is depressed, he or she may be constantly talking about the history of the marriage and relationship. Remember, the "garbage truck" is running in their brain, thinking of every bad thing that has been done, said, or not done. The spouse that isn't depressed is frequently "dumped on" with hundreds of accusations and thoughts that are long after-the-fact and totally beyond correction at this point. The nondepressed spouse may suddenly learn that their partner never did like their hairstyle, their mother, their choice of automobile, or the price of the house. The nondepressed spouse will hear many "thoughts" that were present at the time of marital decisions, often years ago, but were never mentioned. The nondepressed spouse may be awakened at night with accusations and complaints that may last for hours. The nondepressed spouse will be made to feel responsible for these unspoken wishes and will be helpless as the depressed spouse lists mistakes and misunderstandings that have taken place during the entire marriage/relationship. Even though they might have been discussed at the time, the nondepressed spouse will receive much blame for past events.

If your son or daughter is depressed, they may suddenly withdraw from the family or become hostile. Due to their youth, most of their life experience is associated with the family, remembering that family experiences makes up 70 percent of their mental video tape. For this reason, the "garbage truck" will be reviewing every mistake or issue in their upbringing. In such cases, the parents are "dumped on" with what they did wrong, bad decisions they've made in raising the son/daughter, or feelings that were never discussed related to their brothers or sisters. With the low self-esteem created by the depression and stress, the son/daughter may be intensely rejecting, as though feeling they must reject the parents before the parents have a chance to reject them. The anger and hostility is often so strong that parents miss the fact that their son/daughter is depressed - they're too busy dealing with accusations or hostility to see the depressed mood.


Older sons and daughters may start apologizing for their behavior in their childhood, seeking forgiveness - despite the fact that they are now parents themselves. Parents may be shocked to find that their depressed married son/daughter is suddenly thinking of divorce in a circumstance that is "out of the blue" and totally unexpected.

If a friend is depressed, they will suddenly have no interest in maintaining your friendship. They'll stop calling, visiting, or writing. If your depressed best friend suddenly gives you their most prized possession or asks you to be included in their will to take care of their children - be on the alert! Such behaviors are often part of a suicide plan in which the depressed friend wants to "take care of business" before they leave this earth. At that point, a heart-to-heart talk is needed, perhaps offering to accompany them to a professional's office for help. Many depressed individuals are brought to the office by their parents, friends, ministers, union stewards, or work supervisors.

Conclusions:

Depression, at some level, will hit every adult eventually. While most depressions are brief, with our serotonin gradually returning as stress decreases, when depression comes and stays you may need professional treatment to recover. If you think you may have depression, obtain an opinion from a mental health or medical professional. That professional can then guide you in the direction of additional treatment and/or possible medication. Depression is no longer a mystery and is easily treated by modern methods. Treatment is usually short-term, there's no lying on a couch, and your insurance covers most of the charges in Ohio and other states. Your community mental health professionals are your clinical psychologists, psychiatrists, social workers, and those at your community health-care facilities.

Credit: This handout was written by Joseph M. Carver, Ph.D., a psychologist in private practice at Joseph M. Carver, Ph.D., Inc. in Portsmouth, Ohio. Dr. Carver is a psychologist consultant at the Adena Regional Medical Center 1-A Inpatient Psychiatric Unit, River Valley Health Systems, and is affiliated with three regional hospitals. The handout is provided as a public service to the community.