Emotional pain typically drives the quest for psychotherapy.  Pain, after all, is nature’s signal that an organism’s welfare, and survival, are threatened.  Hence, taking action to identify the cause of the pain and to eliminate it are adaptive.  Any psychotherapist, and anyone who has undertaken psychotherapy, will tell you that it is not always easy to identify the cause of the pain and treat it — unlike how we diagnose and treat bacterial infections with antibiotics.  We have no clinically-available biological markers for emotional distress: no blood tests, brain scans, or urine assays.  The pain is no less real than that experienced elsewhere in the body, but explaining it is orders of magnitude trickier and requires more indirect methods of assessment.

Just try finding a word to describe the experience of an emotional ache.  The exercise renders most of us speechless for minutes.  Patient: “It feels bad.”  Therapist: “Yes, but which bad feeling is it?”  Patient: “I don’t know.”  And so the patient and therapist begin the excavation of the layers of his/her emotions and emotional learning history, down the layers of time as far as we can go — working to identify the feeling, its duration, its triggers in real time, and its roots in emotional history.

New research suggests that those layers of emotional learning may go deeper than we might expect.  In a recent study, psychological scientists demonstrated that 1-year-old infants seem to be capable of registering the emotions resulting from social interactions.  After performing a puppet show for the infants, researchers found that the infants could discern when one puppet was mistreated by another.  They could even discern when the mistreatment was accidental or deliberate.  In essence, the infants “…had strong feelings…” about the way the puppets should have treated each other.

Psychotherapists often speculate that some emotional reactions were learned, or emotional raw spots created, so early in life that they are not recorded as explicit memories, that is, memories that are “tagged” with information such as time and place of acquisition.  Rather, some emotional reactions seem to be recorded as implicit memories, typically experienced as something one just “knows” or experiences as “this is just me” without the ability to explain how it came to be.  The observations from this new study offer some tantalizing hints about the information infants can process and understand in their social – emotional worlds and could partially explain the challenge of putting feelings into words.  Some feelings could have been experienced before language development.  The study’s findings may also shine some light on the darkness of our understanding of how the emotional atmosphere of a family leaves its mark.

It is scary to be diagnosed with depression.  However, it’s a lot less scary to be diagnosed with depression when you know that your grandmother and your uncle on your mother’s side also had it.  We may live in the age of biological psychiatry, and the NIH may have just announced their plan to map the human brain http://www.neuroscienceblueprint.nih.gov/connectome/, but we are still haunted by a view of brain illnesses that led our forefathers to drill holes in the skulls of depressed persons to let out the evil spirits.  Stigma is alive and well.  But its impact is reduced by the realization that, “It’s not my fault.”  Moreover, people diagnosed with the illness may be more open to the proven treatments (talk therapy combined with medication) when shown evidence that the predisposition is inherited, not a function of personal failure.   Most of my new patients with the illness have no idea that they are suffering from depression; they just know that they are suffering — sometimes for 30 years.  Without treatment.  Blaming themselves.  Concluding that they are worthless and that their situation is hopeless.

If depression runs in your family, do your children a favor.  Save them potentially years of suffering.  Tell them about it.

In my psychotherapy practice in Baltimore, I see a great deal of emotional pain caused by the view that life is a series of pass / fail tests.  “I chose the wrong job, the wrong wife, the wrong plants for the garden. Hence, I am a failure.”  This attitude is reinforced by the most optimistic adage we have for less-than-optimal outcomes:  Learn from your mistakes.  Even worse, people can become paralyzed in making any decisions if undesired outcomes are generally framed as mistakes.  I propose an alternative viewpoint:

Life is a series of experiments.

Do some experiments and learn about yourself.  Unlike the simplest electronic gadgets, a human body has no user’s guide – no guide for how to create success and contentment.  Creating a satisfying life using our biological endowment and learning history requires experimenting to find out with what we’re good at and what we’re not, what works for us and what doesn’t, what makes us happy and what doesn’t.

Do some experiments.  Make a decision and collect data about the outcome:  I like this / I don’t like this.  Regardless of the outcome, you haven’t passed or failed:  you’ve learned something new about yourself.

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. 

References

1 http://www.nimh.nih.gov/health/publications/depression/symptoms.shtml

2 http://www.nimh.nih.gov/health/statistics/index.shtml

3 http://www.who.int/whr/2003/chapter1/en/index3.html

4 http://www.who.int/mental_health/management/depression/definition/en/

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.

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