CONTENT WARNING: We will be discussing mental illness in this blog post, which includes some graphic examples and depictions of suffering. Be advised.
Being depressed is one of the worst things that will ever happen to you. At the very least, it’ll feel that way. Between 30 and 50% of people will have experienced depression at some point in their lives. Depression is a beast so profoundly connected to the human experience that people have been writing poems about it since forever. We romanticize melancholy because, to some extent, it’s a mystery. Why do people even get depressed? How can a person die of heartbreak? Why don’t people who get depressed just get better? Why do people kill themselves?
You’ve got a lot of questions. Relax. Yes, you can die of heartbreak, but you probably aren’t going to. We’ll get to all of it. To be honest, we’ll get to some of it.
Why Do People Get Depressed?
Just like many other mammals, human beings experience an emotion called sadness in response to loss—that is, the sense that one will never again experience a person, place, thing, or idea in the same way. That’s a broad definition, and it has to be. Human beings are deeply sensitive to loss from a very early age. Take away a child’s toy and watch how they cry. Now give the toy back, you monster. You just elicited the emotion of sadness in the child.
Depression is sadness taken to its extreme. A person can exhibit the symptoms of depression if they experience a significant loss, such as the loss of a loved one or the loss of an idea (as often occurs following rape). A new inmate may begin to isolate himself as much as possible from others. Yes, she could be trying to avoid trouble, or she could be deeply depressed by the loss of her freedom. Both are often the case.
Depression can be an adaptive response to a significant loss. One reason to think this comes from studies into the 5HT1A receptor in the brain. It binds to serotonin, a neurotransmitter that has been highly implicated in depression and that is the target of most antidepressant medications. We have seen that mice lacking the 5HT1A receptor demonstrate fewer depressive symptoms in response to stress, which indicates that the receptor may also function as a sort of “on switch” for depression. This suggests that we evolved depression—that it’s useful to us as a species and helped us, as a population, to survive.
Imagine that you are an anthropomorphic bear, and you just gave birth to a number of adorable little cubs. You go off to get some food for your cubs. By the time you return, you find your cubs murdered—the victims of a cruel game played by human teenagers and their rocks. You lie down on the blood-soaked earth around your cubs and sleep. Eventually your cubs rot, but you stay by their side. You won’t leave them. You go back out and get more food, and you bring it to them. You wonder why they won’t eat. Their little mouths are full of maggots, you reason, and you tear open their little bodies trying to get the maggots out. Then you tear some meat into small chunks and put them into your little cubs’ decaying and now mutilated corpses. Now they’ve eaten, you think to yourself, and you smile.
Depression is terrible, but failing to recognize a loss is worse. The depression that follows a loss is our body’s way of adapting to that loss, the way a fever is the body’s way of fighting illness. It forces you to sit still, to alter your perspective, and ultimately to find a new reason to move. It forces the bear to recognize that her cubs are dead and to move on and try to reproduce again.
Many studies have shown people who enter a depressed state enter a highly analytical state of mind that allows them to break down problems into their component parts in order to find efficacious solutions. In one study, participants who became depressed while working on complex problems on an intelligence test performed better on the test than those who did not.
Unfortunately, the pain that follows a loss doesn’t always heal. For some people, depression can stick around and become chronic. In this case, the bear would lie down and eventually starve herself to death. In the case of a human, depression can lead as far as to suicide.
The Depression Formula
There are a few different depressive disorders: disruptive mood dysregulation disorder, persistent depressive disorder, premenstrual dysphoric disorder, etc. We’re going to focus our conversation on the most common of these: major depressive disorder.
Major depressive disorder is diagnosed when an individual presents with five of the following nine symptoms, which must have persisted for at least 2 weeks and represent a change from functioning prior to the onset of symptoms:
1. Depressed mood most of the day, nearly every day. (In children and adolescents, mood may be irritable.)
2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day.
3. Significant weight loss when not dieting or weight gain, or a decrease or increase in appetite nearly every day.
4. Insomnia or hypersomnia nearly every day.
5. Psychomotor agitation or retardation nearly every day. That is, the individual’s thoughts and actions either appear to speed up or slow down such that others will have noticed.
6. Fatigue or loss of energy nearly every day.
7. Feelings of worthlessness or excessive or inappropriate guilt nearly every day. (Not merely self-reproach about being sick.)
8. Diminished ability to think or concentrate, or indecisiveness, nearly every day.
9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for completing suicide.
Major depression is not diagnosed when the depression is caused by a substance or a medical condition, such as a traumatic brain injury. Major depression is also not diagnosed when a person is presently experiencing a significant loss. This is because, as we now know, depression itself is adaptive after a significant loss, and most people’s feelings of dysphoria following a significant loss tend to decrease in intensity after days or weeks of grieving.
People who are grieving tend also to have consistent self-esteem. That is, people who are grieving do not tend to experience feelings of worthlessness. They may beat themselves up about how long they spent with the deceased, or how they behaved towards the deceased in life, but they don’t generally feel worthless. People who are grieving tend to experience feelings of emptiness and loss, whereas people with major depression tend to develop an inability to anticipate happiness or pleasure. That is, they think of happiness as a thing they are incapable of achieving, rather than as something that is right around the corner if they could only change their perspective.
One of the primary features of major depression is rumination, or that “highly analytical state of mind” we were talking about earlier. The word rumination comes from the Latin word rumen, which means throat or gullet, and initially referred to the process whereby certain mammals regurgitate material (i.e. cud) from their first stomachs (i.e., their rumen) and chew it to break it down further. In major depression, individuals will similarly “regurgitate” negative experiences and thoughts and reconsider them again and again and again.
As with the bear whose cubs were murdered, rumination is helpful only up to a point. There is only so much a bear can do to prevent people from killing her cubs while she is out hunting for food. Rumination can become a death sentence for the bear if it results in her being unable to gather food for herself. Fortunately (or unfortunately), human beings are a social species, and that means we have many more reasons to become depressed, but it also means that we can help each other survive it.
The more severe the depression, the worse the symptoms can get. Rumination can become so overwhelming that the person’s mind effectively stops attempting to interpret reality correctly. The person begins to experience a condition called psychosis, where the individual begins to lose touch with reality around them. They can become isolated, paranoid, and highly irritable. They can even experience hallucinations and delusions. In some of these cases, the best treatment is inpatient care at a psychiatric facility.
Can Depression Kill?
Short answer? Yes. Depression can kill its sufferer in three primary ways.
More common among the elderly, depression can cause a person to neglect their self-care completely. This may not be an active attempt to kill oneself, but it may become deadly given enough time and inattention. People who are severely depressed can experience a condition known as avolition, which is the complete lack of motivation to do anything. A depressed individual may stop showering, grooming, even eating.
Serotonin, the neurotransmitter that has been implicated in depression, also contributes to our motivation. Low quantities of serotonin in the brain can cause a person to experience psychomotor retardation, or a marked slowing down of thought and action, that is plainly visible to an outside observer. It can also result in a marked decrease in appetite, causing a person not to feel hungry despite being obviously starved.
Since older adults are more likely to have serious health issues that consistent care, self-neglect can lead to death in a number of different ways. An individual could fail to take their blood pressure or diabetes medication, creating complications that result in death. For our aging population, who are increasingly isolated in our modern world, self-neglect is a major issue.
Suicide rates have jumped in the period between 1999 and 2016, making suicide the tenth-leading cause of death in the United States. Among people ages 15 to 34, suicide is the second-leading cause of death. There is a lot of speculation as to why suicide rates have gone up, but no one knows for sure why. For a lot of people, the thought of welcoming death seems strange. After all, all biological organisms appear to have a strong survival instinct. If you can imagine how strong the survival instinct is, then you can imagine how powerful depression must be to override it.
The process whereby depression overrides the survival instinct is not one that happens overnight. Like anything else, it takes practice to overcome one’s own fear of injury and death. It begins with cognitions. Individuals who begin to contemplate suicide tend to have two things in common; they feel like a burden to others, and they feel like they don’t belong anywhere. Over time, an individual with depression, locked in rumination, comes to the frightening yet inescapable conclusion that death is preferable to the pain that they are experiencing.
On April 5, 1994, Kurt Cobain shot and killed himself in his home in Seattle, Washington. His body was discovered three days later. Cobain’s suicide did not occur in a vacuum. Despite his success as a musician, Cobain had been actively suicidal since he was 13 years old. He had experienced a very difficult and traumatic childhood full of abuse and neglect. During a 1991 interview, Cobain stated that he didn’t believe in guns. During a suicide attempt earlier in 1994, police had confiscated four guns from his home. In order to kill himself, he obtained a shotgun from a friend, claiming that it was for protection.
Cobain, like many people who complete suicide by firearm, had to inure himself to guns in order to kill himself. He purchased several guns and practiced with them in order to get a handle for them. By 1993, Cobain can be seen posing in several photographs with a gun pointed to his head and mouth. Like many people who complete suicide, Cobain was engaging in rehearsal. That is, he was practicing how he would kill himself by engaging in behaviors that prepared him for what he was planning to do. People who attempt to commit suicide by overdose may research and plan how many pills they will need to kill themselves. They may sort out the pills they need, then put the pills back together and repeat the process.
Suicide rehearsal can become a coping skill for people who struggle with suicidal ideations. The thought of death may come as a relief. It is an ironic sort of hope, indicating that there is an end to the pain in sight, if only the person had the will to take final, irrevocable action.
Surveys of people who attempt suicide by less lethal means indicate that people who attempt suicide regret the attempt, often too late. Bridge jumpers specifically indicated that they tended to regret their attempt the moment they had jumped. All of this is to say that suicidal urge, the overwhelming need to take action now, does not last very long. Some studies indicate that this urge last anywhere from three to five minutes for most people.
This is what makes suicide by firearm the most lethal and common method of suicide. It is difficult to make a different choice once you’ve pulled that trigger. Nearly two-thirds of all gun deaths in the United States are suicides.
You have probably heard of people dying of a broken heart—at least in fantasy literature. Well, it’s a real thing. Takotsubo cardiomyopathy is a disease that weakens the muscular structure of the heart, causing the apex of the left ventricle to bulge.
The causes of takotsubo cardiomyopathy are not fully understood, but 85% of cases were immediately preceded by some sort of physical or emotional stressor. Postmenopausal women are most at risk, with 90% of cases occurring in women, most of them postmenopausal.
Takotsubo cardiomyopathy tends to occur primarily in response to an emotional or physical stressor. In most cases, these are negative stressors—like the loss of a loved one. In some rare cases, the stressor can be a positive one—such as a surprise birthday party. The sudden emotional or physical shock causes the heart muscle to weaken, creating the bulge that gives it its Japanese name: takotsubo, meaning “octopus trap.”
Healing from Depression
Regression to the Mean
Most people who suffer from mild to moderate depression will “regress to the mean.” This is a term meaning that the patient will return to a previous state of functioning over time with no intervention. Some people do tend to improve from depression on their own. These are the lucky ones.
Some people with moderate depression, and anyone with severe depression, would benefit from psychotherapy. A combination of medication and psychotherapy is considered the gold standard treatment for depression.
The psychotherapeutic interventions with the best evidence supporting their efficacy include a few common components. Most include cognitive components, such as dialectical exchange—where a clinician encourages the client to challenge their automatic thoughts during a back-and-forth exchange. Some of these interventions focus on a person’s interpersonal relationships, while others might focus on behavioral changes. In behavioral activation, for example, the clinician encourages the client to engage more with friends or to participate in more activities—to be more active and social, even though it may feel like work in the beginning. Most interventions require that clients complete “homework” assignments, which are designed to allow the client to practice what they’ve learned in therapy out in the real world.
Antidepressants come in a variety of forms. I won’t be able to go through them all, so let’s run through a few quickly.
· SSRIs: selective serotonin reuptake inhibitors: citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine, sertraline
· SNRIs: serotonin and noradrenaline reuptake inhibitors: duloxetine, venlafaxine, desvenlafaxine
· Noradrenaline reuptake inhibitors: reboxetine
· TCAs (tricyclic antidepressants): amitriptyline, nortriptyline, clomipramine, dothiepin, doxepin, imiprimine, trimipramine
· RIMAs (reversible inhibitors of monoamine oxidase A): moclobemide
· Tetracyclic antidepressants: mianserin
· Tetracyclic analogues of mianserin (sometimes called noradrenergic and specific serotonergic antidepressant [NaSSA]): mirtazapine
· MAOIs (monoamine oxidase inhibitors): phenelzine, tranylcypromine
· Melatonergic antidepressants: agomelatine
The most commonly prescribed of these, the SSRIs, tend to be the safest. The other types are only really used when the client is nonresponsive to SSRIs. That is, the medication doesn’t work for them. All of these medications come with their own side effects, and you should definitely read about them online.
The most unusual side effect that comes from taking antidepressant medication is a heightened risk of suicide. This occurs because severely depressed individuals are often too lethargic to take their own lives. They lack the energy to get up and get much of anything done. Starting antidepressants can cause an individual to feel better—not well enough to live, but well enough to go borrow a shotgun from a friend.
Suicidality during the early stages of depression treatment is a serious matter, and this is why clinicians are advised to follow-up with their patients more regularly in the first months of treatment.
More commonly known as electroconvulsive therapy, or ECT, it’s often showcased on TV as a horrifying treatment provided under miserable conditions. In fact, it is now provided under general anesthesia. Small currents of electricity are passed through the brain, intentionally triggering a small seizure. Although no one knows why it works—which I realize lends a little bit of credence to the “horrifying” bit—we do know that it can provide quick relief for individuals suffering from extreme cases of depression and other mental health disorders.
ECT is usually only provided when a person has been shown to be treatment-resistant. That is, nothing else has been working. It is also provided when an individual has become detached from reality and has been threatening suicide. For example, were your sister found stabbing herself in the arms with a shard of glass and singing to herself, “I don’t feel anything,” she might be a good candidate for ECT.
Pregnant women may sometimes opt for ECT in order to avoid harming her fetus with the side effects of medication. Older adults might choose ECT because they can’t tolerate the side effects themselves. There are many reasons that ECT is still done today, and it’s a much more humane procedure nowadays.
Magic and Speculative Science
If you’re writing science fiction or fantasy, there are a few other things you might consider.
As we continue to learn about the brain, we may quickly learn that there are physical correlates to depressive emotional states. That is, there are changes in the brain when a person becomes depressed. If we can somehow learn to change the structure of the brain—to undo the changes that caused the depression—we may eliminate the depression. It’s possible, we may eliminate a lot more than the depression in so doing, however—memories, important aspects of the person’s personality—at this point, we have no way of knowing.
Magic could temporarily remove depression. A quick spell could easily alter the biochemical ratios in the brain, creating any feeling that the magic user wanted to create. This would be akin to taking a fast-acting antidepressant (which do not presently exist, but could in your story). Do be aware that any antidepressant-like effect is going to bring with it some side effects—including an increased risk of suicide.
In order for magic to cure depression permanently, it would have to alter the structure of the person’s brain. Again, this would potentially alter the person’s memories and personality. There is no way of knowing the extent of the effect “curing” depression would have on a human brain. It may be for the better…it may not.
Magic or psi could also attempt to cure depression over time by changing an individual’s outlook—a form of subtle mind control. Over time, an individual who has been “trained” thus to see the world in a certain way would indeed begin to see the world in that way. The brain structure will have been altered naturally, over time, through conditioning.
Or do what you want. It’s magic.
Thank you for joining us on our adventure through the wild and awful land of depression. Come back next month to see us explore mania and the caprices of bipolar disorder!