Depression is a disorder of the organism that affects many bodily (including mental) functions as well as the organism’s ability to function in its environment. It is characterized by disturbances in mood, cognition, attention, behavior, and neurovegetative functions. It has multifactorial causation with contributions from genes, epigenetic influences on gene expression, other biological factors including temperament, early life experiences, recent and current social-cultural-life stressors, and habitual deployment of maladaptive coping strategies, among other factors.

Is major depressive disorder a disease? You can call it that if you wish. After all, the AMA classifies obesity as a disease. It is less important whether MDD is a disease or instead some other form of disturbance than it is to avoid the pitfalls of treating MDD as a simple type of disease. Even if you consider MDD a disease, it should be treated as a special (even if not unique) type of disease. Let me illustrate:

Consider an infection with influenza. After a clinician has diagnosed a person with the flu, then the clinician can prescribe a form of disease-modifying antiviral medication, such as oseltamivir or zanamivir, and one or more symptom-relieving medications, such as decongestants, expectorants, analgesics, hypnotics, etc. After getting a quick handle on the nature of the symptoms that can be ameliorated through symptom-relieving meds, the clinician is done. Nothing more need be said. The clinician does not need to delve into details of each symptom and then discuss it at length because such a focus would not alter the diagnosis nor the treatment.

The same is not true of MDD (among many other psychiatric disorders). In MDD, the cause is not a virus that can be identified and treated directly and through symptom relief. In MDD, the causes are not only multi-factorial but include the symptoms themselves. The cause-effect relationship is circular, the symptoms of MDD are also some of its causes. MDD is a condition that arises out of vicious cycles or circles. Vicious cycles arise from positive feedback loops among causes and effects and these loops have deleterious consequences. Positive feedback refers to the relationship among factors: an increase of a symptom feeds back to cause further increase of that and other symptoms. In effect, depressive symptoms lead to depressive symptoms lead to depressive symptoms and so forth indefinitely.

In a condition with this type of complex, dynamic, circular causality, the symptoms become crucial to understand and address. This is not only to be able to provide adequate symptomatic relief but, by virtue of providing symptomatic relief, it is also to provide disease-modifying treatment: treating depressive symptoms decreases the causal inputs into the depression. Here are some examples:

  • Depression often disrupts sleep and disrupted sleep maintains depression.
  • Attentional biases and cognitive distortions predispose to and worsen in depression and, circling back, worsen the depression.
  • Depression leads to isolation and low motivation, and isolation and low motivation in turn deepen and maintain depression.

So, one limiting frame for understanding depression, one often shared by patients and clinicians, is to think of depression (and other psychiatric disorders) as a simple disease, as one with a one-way relationship between cause and effect; cause leads to effect but effect does not become a cause. An example, depression is a chemical disturbance. Let’s treat the chemical disturbance and, if it works, the symptoms will resolve.

If however, both clinician and patient come to understand that the symptoms of depression are to large extent also its causes, then identifying the nature of the symptoms and treating them as soon and as aggressively as possible takes on greater saliency. Consider the patient with depression and poor sleep. Under this view, addressing the sleep disturbance is seen as a disease-modifying intervention and not only as symptom relief. This view can more quickly spur the clinician to implement sleep hygiene measures and to prescribe a hypnotic now rather than to wait to see how the sleep disruption responds to the antidepressant. Or the patient with isolation and low motivation; the clinician can now understand these symptoms not only as effects of depression but also as its causes. Such a characterization is much more likely to spur the clinician to implement behavioral activation techniques now and not sometime later or perhaps not at all.

I want to give an example of how this ‘vicious circle’ understanding of depression can be used to implement a more comprehensive form of treatment, even by a clinician primarily doing medication administration. A patient presents to a clinic and is assessed and diagnosed with MDD. The patient is prescribed an anti-depressant and given psychoeducation about MDD and the prescribed medication. Before the patient leaves, the clinician gives the patient an additional assignment,

“We’ll see each other in two weeks for follow up. In the meantime, I have a simple assignment for you. For most people with depression, their depressed mood fluctuates from one part of the day to another and from one day to the next and the better we understand your depression, the more we can effectively treat it. My assignment for you is this: each evening for 15-20 minutes, reflect on your day and write down how your mood changed over the day. Write down what was going on that could have made the depression better or worse at that point in your day. If we can learn what situations, thoughts, or behaviors make the depression better, worse, or just different, then we can work to lessen the bad stuff and increase the good stuff. Try it. For most people it is an eye-opening experience, and they feel better because the depression starts to make a bit more sense. If you miss an evening of jotting your notes, you can try to catch up the next day or just skip it. We don’t need perfection. Take care and I can’t wait to hear in our next visit what you have learned.”

Thanks,

Dr. Jack

 

Language Brief

“My own brain is to me the most unaccountable of machinery – always buzzing, humming, soaring roaring diving, and then buried in mud. And why? What’s this passion for?” ― Virginia Woolf

“I think we are well advised to keep on nodding terms with the people we used to be, whether we find them attractive company or not. Otherwise they turn up unannounced and surprise us, come hammering on the mind’s door at 4 a.m. of a bad night and demand to know who deserted them, who betrayed them, who is going to make amends.” – Joan Didion

“But maybe it’s the laboring that gives you shape. Might the most fulfilling times be those spent solo at your tasks, literally immersed or not, when you are able to uncover the smallest surprises and unlikely details of some process or operation that in turn exposes your proclivities and prejudices both?”  ― Chang-rae Lee