Symptoms of Depression

The National Institute of Mental Health (NIMH)1 provides this list of symptoms:

* People with depressive illnesses do not all experience the same symptoms. The severity, frequency and duration of symptoms will vary depending on the individual and his or her particular illness.

* Persistent sad, anxious or “empty” feelings

* Feelings of hopelessness and/or pessimism

* Feelings of guilt, worthlessness and/or helplessness

* Irritability, restlessness

* Loss of interest in activities or hobbies once pleasurable, including sex

* Fatigue and decreased energy

* Difficulty concentrating, remembering details and making decisions

* Insomnia, early–morning wakefulness, or excessive sleeping

* Overeating, or appetite loss

* Thoughts of suicide, suicide attempts

* Persistent aches or pains, headaches, cramps or digestive problems that do not ease even with treatment

Statistics for the United States   The estimated one-year prevalence of depression is 7.1% of the population.2  According to the World Health Organization (WHO), globally, “more than 150 million people suffer from depression at any point in time; nearly 1 million commit suicide every year.”3 Depression is the leading cause of disability, or lost years of productive life.4  Mental illness accounts for over 15 percent of the burden of disease, more than the disease burden caused by all cancers.2  Despite all this, and unlike cervical, colon, prostate and breast cancer, there are no guidelines for depression screening in primary care settings.  

What depression is

It is a treatable, medical illness.

It is still depression, and still treatable, even it if occurs in reaction to a life event.

In some people it is a chronic illness, like hypertension.  Just as for hypertension, treatment is lifelong.

It runs in families, although no simple genetic cause has been identified.

With no available medical test, it is diagnosed through clinical interview, clinical observation, and, ideally, family input.

What depression is not

It is not feeling sad for a day or two.

It is not a character flaw.

It cannot be eliminated by willpower.

It is not who you are; rather, it is something that you have.

Treatment for depression is not a crutch.  

Treatment for depression

It has been known for decades that the best treatment for depression is a combination of  psychotherapy (talk therapy) and medication (Weissman et al, 1979; Weissman et al, 1981).  

Psychotherapy for depression consists of education, cognitive-behavioral and interpersonal interventions, and supportive structure.  The goals of the combined treatment are symptom reduction, improved coping and problem solving skills, and other goals unique to the individual.  Ultimately, treatment for depression should increase your ability to manage the illness on your own.  

Antidepressant medication affects the neurotransmitters in your brain to reduce or eliminate symptoms. There are many different antidepressants. You and your psychiatrist will work together to find the best medicine with the fewest side-effects for you. 

If you have depression and are not being treated, you are suffering unnecessarily. Relief is available. Contact me or talk to your family doctor. 






Weissman MM, Prusoff BA, Dimascio A, Neu C, Goklaney M, Klerman GL. The efficacy of drugs and psychotherapy in the treatment of acute depressive episodes. Am J Psychiatry 136(4B):555-558, 1979.

Weissman MM, Klerman GL, Prusoff BA, Sholomskas D, Padian N. Depressed outpatients. Results one year after treatment with drugs and/or interpersonal psychotherapy. Arch Gen Psychiatry 38 (1):51-55, 1981.


The Triune Brain

Blame it on your 3-part brain, each part the product of a different phase in evolutionary time.  Emotions live in the limbic brain; thoughts live in the neocortex.  Emotional information gets lost in translation.   


(Figure adapated from

Codependent: A word that should be banned from our vocabulary.

During the 1980’s, the term “codependent” entered the popular press with the publication of such books as “Codependent No More.”  Regardless of what the author, Melodie Beattie, intended, the word has come to be synonymous with being excessively emotionally dependent on an other person.  The problem with the term, as it has come to be used, is its implication that depending on another human is somehow pathological.  Nothing could be further from the truth.

Two decades of research on the formation of attachment bonds in humans and other mammals demonstrates that we are shaped by evolution to need one another.  Hence, we are all dependent.  Worse, a great deal of our suffering is caused by the starvation of our attachment needs.  In my practice as a psychotherapist and marriage counselor / couple therapist in Baltimore, I witness the anguish caused when these needs go unmet. 

Do us all a favor; stop using the word codependent.  The next time you feel tempted to use it, remember that our brains are hard-wired for mutual dependence.

Research tells us that “marital deterioration is one of the leading causes of human suffering.”1 Persons in troubled relationships are at greater risk for depression2,3,4 and lowered immune function,5 and are less likely to attend to their health.6 Compared to persons who are satisfied with their relationships, those in distressed relationships miss more work, are less productive in their work, and push harder to accomplish everyday tasks.7 In addition, they have fewer positive interactions and more negative interactions with friends and relatives; they describe themselves as more distressed.7 Moreover, the children in these families have problems in school, behavior and health.8

The research also tells us that couples wait too long to seek outside advice and guidance9,10 and that long delays, years in many cases, make the problems more challenging to resolve.11,12 Less than a third of divorcing couples ever seek professional help.10,13 And, whereas couples worry about the effect of divorce on their children, research shows that marital strife preceding divorce accounts for most of the hardship on children.8

Fortunately, the research demonstrates that some couple therapy methods are effective.14 Among these are behavioral couple therapy, emotion focused couple therapy,15 and a method that combines features of both behavioral and emotion-focused approaches called integrative behavioral couple therapy.16 In one review of empirically-supported therapies, the authors said, “…in no published study has a tested model failed to outperform a control group. In virtually every instance in which a bona fide treatment has been tested against a control group, the treatment has shown reliable change” (page 85).17

Finally, there are promising results from recent studies supporting the value of a relationship checkup, akin to the annual physical checkup.1,18 The value of this approach is the likelihood of identifying problems when they are small and can be more easily addressed, and while the couple has enough mutual goodwill for a collaborative effort to improve the relationship.

Essentially, what the research tells us about marriage and couple counseling is that troubled marriages are destructive to the couple and their children and that couples wait far too long before getting help, if they get help at all. To increase their odds of success, distressed couples should find a psychotherapist who practices one of the empirically-supported couple therapy methods – sooner than later.


1. Cordova JV, Scott RL, Dorian M, Mirgain S, Yaeger D, Groot A. The marriage checkup: An indicated preventive intervention for treatment-avoidant couples at risk for marital deterioration. Behavior Therapy 36:301-309, 2005.

2. Hooley JM, Teasdale JD. Predictors of relapse in unipolar depressives: Expressed emotion, marital distress, and perceived criticism. Journal of Abnormal Psychology 98:229-237, 1989.

3. Paykel ES, Myers JK, Dienelt MN, Klerman GL, Lindenthal JJ, Pepper MP. Life events and depression: a controlled study. Archives of General Psychiatry 21:753-760, 1969.

4. Weissman MM. Advances in psychiatric epidemiology: Rates and risks for major depression. American Journal of Public Health 77:445-451, 1987.

5. Newton TL, Kiecolt-Glaser JK, Glaser R, Malarkey WB. Conflict and withdrawal during marital interaction: The roles of hostility and defensiveness. Personality and Social Psychology Bulletin 21:512-524, 1995.

6. Schmaling KB, Sher TG. Physical health and relationships. In WK Halford & HJ Markman (Eds.), Clinical Handbook of Marriage and Couples Interventions (pp. 323-336). Chichester: Wiley & Sons, 1997.

7. Whisman MA, Uebelacker LA. Impairment and distress associated with relationship discord in a national sample of married or cohabiting adults. Journal of Family Psychology 20:369-377, 2006.

8. Cherlin AJ, Furstenberg FF, Chase-Lansdale PL, Kiernan KE. Longitudinal studies of effects of divorce on children in Great Britain and the United States. Science 25:1386-1389, 1991.

9. Bowen GL, Richman JM. The willingness of spouses to seek marriage and family counseling services. Journal of Primary Prevention 11:277-293, 1991.

10. Wolcott IH. Seeking help for marital problems before separation. Australian Journal of Sex, Marriage and Family 7:154-164, 1986.

11. Snyder DK. Marital Satisfaction Inventory, Revised. Los Angeles: Western Psychological Services, 1997.

12. Snyder DK, Mangrum LF, Wills RM. Predicting couples’ response to marital therapy: A comparison of short- and long-term predictors. Journal of Consulting and Clinical Psychology 61:61-69, 1993.

13. Albrecht SL, Bahr HM, Goodman KL. Divorce and remarriage: Problems, adaptations, and adjustments. Westport, CT: Greenwood Press, 1983.

14. Baucom DH, Shoham V, Mueser KT, Daiuto AD, Stickle TR. Empirically supported couple and family interventions for marital distress and adult mental health problems. Journal of Consulting and Clinical Psychology 66:53-88, 1998.

15. Johnson SM, Hunsley J, Greenberg L, Schindler D. Emotionally focused couple therapy: Status and challenges. Clinical Psychology: Science and Practice 6:67-79, 1999.

16. Christensen A, Atkins DC, Berns S, Wheeler J, Baucom DH, Simpson LE. Traditional versus integrative behavioral couple therapy for significantly and chronically distressed married couples. Journal of Consulting and Clinical Psychology 72(2):176-191, 2004.

17. Jacobson NS, Addis ME. Research on couples and couple therapy: What do we know? Journal of Consulting and Clinical Psychology 61:85-93, 1993.

18. Cordova JV, Warren LZ, Gee CB. Motivational interviewing as an intervention for at-risk couples. Journal of Marital and Family Therapy 27(3):315-326, 2001.

copyright Ann-Marie Codori 2009

If you are curious about this, you have probably already experienced the intense emotions that accompany serious romantic relationships, married or otherwise. From the excitement of the early days, to the sense of comfort and security that accompanies commitment, to the anguish of feeling separate when something goes wrong, our most intense emotions occur in the context of our intimate partnerships. A growing body of research is revolutionizing couple therapy by demonstrating that these emotions are part of a neurobiological system in humans, and other mammals, that is the basis of social bonding (Carter, 2005; Insel & Young, 2001; Young et al, 2011). To the list of other instinctive needs, such as the needs for food and sleep, we can now add the need for an emotionally secure relationship, or attachment, with another human being. In adulthood, disruptions in the security of these partnership attachments are at the root of emotional distress in couples. Emotionally focused couple therapy (EFT) specifically targets these intense attachment-related distress-emotions with a structured, step-by-step therapeutic method. The focus on emotions that are signals of attachment-related problems and the structured method are what sets EFT apart from other couple therapies.

Part 1: Emotions

The emotions, joy, fear, anger, sadness, shame, surprise are part of the universal experience of being human — even being mammalian (Panksepp, 1982). They are part of a neural system that evolved over millions of years to alert us to situations in our environment that require action. Fear cues us to protect ourselves. Calmness tells us that we are safe and can let down our guard. Without emotions to alert us to the dangers in our environment, we don’t survive. Emotions are adaptive as part of the fight – flight – freeze response when we perceive and anticipate danger (Panksepp, 1998). Put simply, emotions are part of a psychobiological self-protection program.

Most of us are more familiar with the protective features of our peripheral nervous system. After burning their fingers once or twice, children learn quickly to avoid touching a hot stove. The experience of hot and cold, soft touch and deep pressure signal us about the safety of, first, our skin – our first line of defense. If you submerged your hand in boiling water, the burning pain instantly signals you to remove your hand from danger. Similarly, we know that we are hungry because of sensations (and noises!) in our stomachs. When our eyelids close involuntarily, our bodies feel heavier than usual, and we find it hard to concentrate, we conclude that we are tired. These sensory experiences are messages about the status of our physical safety and well-being. We stay healthy when we respond to these cues by doing what our body is telling us: eat now, sleep now, don’t put your hand in boiling water!

Likewise, the emotions we feel in our intimate relationships signal us about our psychological safety and well-being. Calmness and relaxation, breathing easily, and a sense of peace with our partner typically signal that all is well in the relationship: the need to feel safe and secure with our partner is being met. And, like burning pain and hunger, that knot in your stomach may reflect your uncertainty about whether your mate really loves you. You may notice a heaviness in your chest when you feel sad and unimportant to your partner. Or you may feel numb or dead inside, trying to anesthetize yourself against the despair of isolation from your spouse. These are psychophysiological messages that something is amiss in our attachment relationship: our need to feel safe and secure is not met. The signal means do something to reestablish a safe, secure connection. It is an elegant system that works well, if we pay attention to the psychophysiological messages and take action.

System failure has a few common causes. We may not be paying attention to the emotional sensations and experiences. We may note the sensations, but not know how to decipher their meaning or know what to do about them. Or our actions may be perpetuating the distress. When both members of the couple struggle with understanding their attachment emotions, and act in ways that unwittingly increase the distressing emotions, a negative interaction cycle forms. Quickly, the couple’s cycle becomes habitual, automatic, and painful. Though they want to feel close and connected, they end up feeling distant and isolated.

That is where EFT comes in. It reconfigures the habitual cycle that create distress and distance by targeting the emotions that drive the cycle. The goal of successful EFT is a new interaction cycle that is attuned to and meets the attachment needs of both partners (Johnson, 2004). The research shows that couples who successfully complete EFT retain the benefits of treatment as long as three years after it ends (Halchuk et al, 2010) and, in some cases, show continued improvement even after treatment ends (Clothier et al, 2002).

To read more about attachment needs and the negative cycles that are typical among couples, read Hold Me Tight by Susan Johnson. 

Coming soon: Part 2, What is Attachment?


Broad KD, Curley JP, Keverne EB. Mother-infant bonding and the evolution of mammalian social relationships. Philosophical Transactions of the Royal Society, Biological Sciences 361(1476): 2199-2214, 2006.
Carter CS. Biological perspectives on social attachment and bonding. In: CS Carter, L Ahnert, KE Grossman, SB Hrdy, ME Lamb, SW Porges, N Sachser (Eds), Attachment and Bonding: A New Synthesis (pp 85-100). Boston: Massachusetts Institute of Technology Press, 2005.
Clothier P, Manion I, Gordon-Walker J, Johnson SM. Emotionally focused interventions for couples with chronically ill children: A two year follow-up. Journal of Marital and Family Therapy 28:391-399, 2002.
Halchuk RE, Makinen JA, Johnson SM. Resolving attachment injuries in couples using emotionally focused therapy: A three-year follow-up. Journal of Couple & Relationship Therapy: Innovations in Clinical and Educational Interventions 9(1):31-47, 2010.

Insel TR, Young LJ. The neurobiology of attachment. Nature Reviews 2:129-136, 2001.
Johnson SM. The Practice of Emotionally Focused Couple Therapy. New York: Brunner-Routledge, 2004.
Panksepp J. Affective Neuroscience: The Foundations of Human and Animal Emotions. New York: Oxford, 1998.
Panksepp J. Toward a general psychobiological theory of emotions. Behavioral and Brain Sciences 5(3): 407-467, 1982.
Young KA, Gobrogge KL, Liu Y, Wang Z. The neurology of pair bonding: Insights from a socially monogamous rodent. Frontiers in Neuroendocrinology 32(1):53-69, 2011.

copyright Ann-Marie Codori 2012

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