Depression ... or Just the Blues?

"Doesn't everybody get depressed at some point?"

It is a common question -- one that you may have even asked yourself from time to time -- but the answer may be more complex than you think.

You may wonder whether you have had depression yourself, or you may have had a depressive episode already but consider it normal.

Even at the clinical level, proper diagnosis of depression can sometimes be a challenge. Just last week, a new study published in the journal The Archives of General Psychiatry suggested that about one in four people diagnosed with depression might instead be struggling with emotions associated with the loss of a loved one or a job, or some other event in the person's life.

The researchers suggested that those emotions, though profound, should not usually be diagnosed as depression.

However, many people think they know what depression is because the word is used in common parlance to mean "sadness."

True, sadness can indeed be a symptom of clinical depression or major depression, but when psychiatrists think of depression, we think of what is called a syndrome -- meaning a collection of signs (what other people can see) and symptoms (what a person feels) that occur together.

Depression Goes Beyond Sadness

The most obvious symptom of depression is the abnormal mood, which is often sadness. But surprisingly, your mood does not have to be sad. Often, rather than being sad, when they are depressed, people say they feel empty, or feel nothing, or feel numb. Rather than bad feelings, there are no feelings.

People often lose the ability to enjoy things; even sex, the universal pleasure, loses its appeal. Their favorite hobbies, such as sailing or dancing, no longer excite them.

They may feel badly about themselves, believing that they do not deserve to be happy, or they may feel guilty for no good reason, blaming themselves for something of little consequence, or for which they had no role. One patient believed he should have been able to prevent the World Trade Center attack. This sort of irrational belief is referred to as a delusion, and occurs in about 15 percent of depressions.

James Potash is an associate professor of psychiatry and co-director of the Mood Disorders Program (http://www.hopkinsmedicine.org/moods) at the Johns Hopkins School of Medicine in Baltimore. If you have questions or comments, please e-mail at moods@jhu.edu. To participate in our studies, call 1-877-MOODS-JH.

Energy is often low. Sleep is often disrupted, with a common pattern being trouble sleeping at night, and excessive sleeping during the day. Appetite often decreases with a loss of weight, though sometimes people eat too much and gain weight.

An underappreciated aspect of depression is the degree to which thinking can be impaired. People have trouble concentrating and often cannot read or retain what they read. One patient whose job involved running complex computer programs sat in front of her computer for months unable to figure out which buttons to push. People may be slowed down and look like molasses, or conversely, they may appear nervous and agitated, wringing their hands and pacing.

The Danger of Suicide

The most worrisome symptom of all is suicidal thoughts. People with depression often think about death.

They may wish they were dead, for example, wishing they did not wake up in the morning. Worse, they may think about ways of actively harming themselves, such as by overdosing on pills, cutting themselves, hanging themselves or using a gun.

Those with thoughts of harming themselves are the group of depressed people who need immediate attention from a psychiatrist or from an emergency room staff, and they frequently need to be hospitalized for their protection until the depression comes under better control.

About a quarter of people with major depression make a suicide attempt in their lives and about 6 percent actually die by suicide.

The Roots of Depression

According to the rule book that guides how psychiatrists and mental health professionals classify mental disorder, a person must have five of the above mentioned signs and symptoms for at least two weeks in order to have a major depressive episode. And these signs and symptoms have to cause problems, such as trouble getting to work, trouble functioning at work, trouble in a marriage or trouble in one's social life.

So where does depression come from? Is it something that everybody experiences at some point?

James Potash is an associate professor of psychiatry and co-director of the Mood Disorders Program (http://www.hopkinsmedicine.org/moods) at the Johns Hopkins School of Medicine in Baltimore. If you have questions or comments, please e-mail at moods@jhu.edu. To participate in our studies, call 1-877-MOODS-JH.

Psychiatrists have long struggled with the question of nature vs. nurture in thinking about the origins of depression. And the struggle continues because the final verdict is not yet in.

The "doesn't everybody experience it at some point?" question assumes that difficulties in life -- stressors -- lead to depression, and because everybody faces them, everybody must get depressed.

We certainly see evidence for this: One woman became depressed following divorce and stayed depressed for the next 10 years. Another woman who was a teacher became depressed following being physically attacked by a student.

While the rain falls on everyone, not everyone gets wet. Some people carry umbrellas, while others do not.

Research has shown that there is a genetic susceptibility to depression. The disorder tends to run in families. And identical twins are more likely to both have depression than are fraternal twins, presumably because they share the same set of vulnerability genes, whereas the fraternal twins are only half genetically the same (just like ordinary siblings).

Our group at Johns Hopkins is conducting a study, along with five other research groups at academic medical centers around the country, where we are trying to pin down exactly which of the 25,000 genes that make up our common DNA blueprint are the ones that play a role in depression.

I will explain this work further in future columns. We are currently enrolling people with depression in the study. To participate, you have to have a sibling or a parent who also has had depression (though they will not be enrolled in the study).

We are hoping that genes will unlock doors that will lead us into biochemical pathways in the brain through which depression unfolds.

Once we have access to the inner workings of the illness, we should be better able to design new medications to help the one-third of patients who do not respond to existing antidepressants.

James Potash is an associate professor of psychiatry and co-director of the Mood Disorders Program (http://www.hopkinsmedicine.org/moods) at the Johns Hopkins School of Medicine in Baltimore. If you have questions or comments, please e-mail at moods@jhu.edu. To participate in our studies, call 1-877-MOODS-JH.

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