Is it Sadness or Clinical Depression?

Sadness is a human emotion. Depression is a long-term illness.

It is normal to feel sadness occasionally due to disappointments faced, loss of loved ones, or other upsetting and difficult life events. Oftentimes, we learn to cope or deal with these situations. However, if low feelings are coupled with a sense of hopelessness, and low self-esteem and persist for prolonged periods of time, even interfering with daily functioning, it could be symptomatic of depression. Depression is a mood disorder which cannot simply be willed away. It is a serious medical condition which needs to be treated.  

Clinical Features 

A person may have a depressive illness if he/she experiences ≥5 of these symptoms for >2 weeks, and at least one of the symptoms should be either (1) depressed mood or (2) loss of interest or pleasure: 

1. Depressed mood – feeling down, empty, hopeless, irritable 
2. Loss of interest or pleasure in hobbies/activities once enjoyed
3. Sleep disturbances e.g. insomnia (difficulty falling asleep or staying asleep), hypersomnia (sleeping excessively)
4. Changes in appetite or weight
5. Fatigue or low energy 
6. Feeling worthless or guilty
7. Recurrent thoughts about death, suicide, or self-harm
8. Poor concentration, difficulty making decisions
9. A slowing down of thought and a reduction of physical movement (observable by others)

The individual should have impairment in psychosocial functioning, and the symptoms observed are not associated with the effects of a substance or another medical disorder. 

Causes of Depression

Depression may result from a complex interaction of biological, psychological, and social factors:

• Biological

• Genetics 
• Genes contribute to vulnerability toward acquiring major depression disorder by 37-38%. A family history of depression or other mood disorders increases your risk of developing depression.
• Heritability has a larger role in women (42%) than in men (29%) and is more common at an early age of onset (18 years old and below). 
• Brain structure/chemistry

• • Some experts think being born with a smaller hippocampus predispose you to depression. The hippocampus is part of the brain that is involved in the storage of memories. A smaller hippocampus has fewer serotonin receptors. Serotonin is one of many neurotransmitters (brain chemicals) that is involved in communication across pathways processing emotions.

• Psychological
  • Stressful life events can predispose to developing depression, e.g.
    • Childhood adversity e.g. abuse/neglect, parental divorce
    • Getting a divorce
    • Losing a job or income
    • Death of a loved one
    • Being a victim of physical/sexual assault
    • Contracting a major illness

• Social 
  • Isolation/poor social support
  • Relationship problems
  • Financial problems and perceived low social status
  • Having close family members or friends with depression. The closer the relation, the higher the risk for depression. Association disappears at four degrees of separation. Female friends are more likely to spread depression on social networks. 

Secondary Depression 

Secondary Depression is due to an existing medical condition such as neurological disorders, terminal illness, and dermatologic disorders which impair functioning or cause disability, affecting mood and self-esteem. There are also medications that trigger depressive syndromes such as glucocorticoids and interferons. Substance abuse (drugs, alcohol) is associated with depression as well. Depression is twice as likely to occur in individuals who use cannabis. 

Treatment 

Treatment usually involves a combination of medication, psychotherapy, and lifestyle adjustments.

Medication

Antidepressants affect changes in brain chemistry and communication in brain nerve cell circuitry known to regulate mood. They do so by tweaking the levels of neurotransmitters (brain chemicals) i.e. mainly serotonin, norepinephrine, and dopamine.

• • SSRIs (selective serotonin reuptake inhibitors) are the most often prescribed antidepressant. They improve how brain circuits use serotonin e.g. Escitalopram (Lexapro), Fluoxetine (Prozac), Sertraline (Zoloft)
  • SNRIs (serotonin and norepinephrine reuptake inhibitors) affect brain circuits that use both serotonin and norepinephrine e.g. Venlafaxine (Effexor), Desvenlafaxine (Pristiq), Duloxetine (Cymbalta)

• Tricyclic antidepressants (TCAs) help keep up the levels of serotonin and norepinephrine in the brain e.g. Imipramine, Amitriptyline

• Atypical antidepressants change the levels of serotonin, norepinephrine, and dopamine e.g. Bupropion (Wellbutrin SR/XL), Mirtazapine (Remeron)

With most of these medicines, common side effects may include diarrhoea, nausea and vomiting, sexual dysfunction, somnolence, and weight gain. It may also take one to three weeks before changes occur. Energy levels or sleeping and eating patterns, for example, may improve before the depressed mood lifts. For the full effects of medications to kick in, they should be continued for six to 12 months (or longer) as instructed. 

Psychotherapy

During psychotherapy, a person with depression talks to a licensed mental health care professional who helps the person identify and work through factors that may be triggering the depression. 

Psychotherapy may be conducted one-on-one, or in a group setting. There are various approaches e.g.:

Psychodynamic Therapy

• Based on the assumption that a person is depressed because of unresolved, generally unconscious conflicts, they are often stemming from childhood. 

• The goal is for the patient to understand and better cope with negative feelings by talking about the experiences. 

Interpersonal Therapy

• It focuses on the behaviours and interactions a depressed patient has with family and friends. 
• The primary goal is to improve communication skills and increase self-esteem. 

Psychodynamic and interpersonal therapies may last ≥3 to 4 months and are usually helpful for depression caused by loss (grief), relationship conflicts, and role transitions (such as becoming a mother or a caregiver).

Cognitive Behavioural Therapy (CBT)

• Helps people with depression identify and change inaccurate perceptions that they may have of themselves and the world around them. 

Lifestyle Adjustments

The following are ways to ensure a healthy mind and body, to complement depression treatment:

• Exercise can increase your body’s production of endorphins, which are hormones that improve your mood – Aim for 30 minutes of physical activity 3 to 5 days a week. 

• Eat a healthy diet. Limit food high in refined sugars and saturated fat; eat more protein-rich lean meats, and complex carbohydrates (e.g. whole grains, fruits and vegetables) as these are involved in the synthesis of neurotransmitters (messengers in the brain).
• Get adequate sleep. Fatigue from lack of sleep can exacerbate depression. Develop a calming bedtime routine to help you wind down and follow a consistent sleep schedule to improve the amount and quality of sleep.

• Learn how to manage to stress e.g. 
  • Engage in an old hobby or cultivate a new one 
  • Read a good book
  • Listen to soothing music
  • Document thoughts/feelings in a journal
  • Watch a good movie
  • Go out with friends for a meal
  • Learn meditation techniques e.g. yoga
  • Confide in family or friends
  • Join a depression support group

Conclusion

Depression is a serious mental health illness with the potential for complications (e.g. substance abuse, suicide) if left untreated. It is imperative to seek medical attention soonest if depression is suspected. Although treatment oftentimes is not completely curative, it can render symptoms more manageable, and ensure good quality of life.