Am I Depressed?
Counseling Psychotherapy, Todos Santos, Cabo San Lucas, Baja California, Mexico
Often I receive questions by e-mail, both from clients who have completed therapy or who are away from Baja California, as well as questions from people I have never met personally.
The latest question or two can be viewed at "ask dr-robert," and previous questions may be found in the ask dr-robert archives.
One reply, however, to the question "Am I Depressed?" has been received with such interest, and has elicited so many favorable comments, both from therapy clients and from professional colleagues, that I decided to keep it on the site as a permanent fixture so that it would always be available and right at hand for easy viewing. The question deals with the difference between depression and ordinary feelings of sadness, and discusses the proper treatment of depression with psychotherapy alone or with therapy in combination with medication. Before reading, please be aware that the advice on this page is not intended to replace the personal relationship between patient and physician or therapist.
Dear Dr. Robert--Sometimes for no apparent reason I begin to feel terribly sad and lonely, and I wonder if life really is worth living. A friend told me that my brain chemistry was off, and gave me some of her Zoloft [antidepressant medication] but taking it did not seem to help at all. My friend said that if I really was depressed, the medication would have made me feel better, so she says I am not depressed, only sad because of things that have happened in my life. She said that depression is a disease, and not just feelings of sadness. But what is the difference between sadness and depression, and, even though the Zoloft did not help, could I still really be depressed?
J.R., Cabo San Lucas
Your letter raises many questions, and I will try to take them one by one. But the most important point is this: depression is not merely sadness. True depression is a serious condition which, without proper treatment, almost always gets worse. And, the longer depression is allowed to continue without proper intervention, the harder it becomes to treat.
Now, depression is not just one particular condition, but rather the word is applied to many different combinations of states of mind, bodily experiences, and emotional attitudes. For example, Person X, in mourning for a beloved partner, relative, or dear friend, might feel extremely sad for a long time, and might also wonder if life is worth living without the continued presence of the beloved, but this person might not be depressed in the sense of suffering from a disease which needs medical attention. Ordinarily, with the passage of time, the normal healing process inherent in mourning comes full circle, and the sadness will change into acceptance, understanding, and, often, a richer view of life. If help is needed, some psychotherapy might be appropriate, usually without the use of medication.
Someone else, Person Y, might apparently feel much less sad, than Person X, but other indications would tell a trained professional that Person Y is depressed in the clinical sense, and that both psychotherapy and medication are required--perhaps urgently.
A third person, Person Z, might have few feelings of sadness at all, or none, but still might be depressed in a way which will require treatment. Depression is not always marked by feelings of sadness. Sometimes depression manifests through other symptoms, such as loss of interest in life, inability to enjoy activities previously enjoyed, sudden changes in eating and sleeping patterns, sudden weight gain or weight loss, feelings of unworthiness, and many other indications which will suggest to the professional that treatment for depression may be indicated.
This is all to say that your friend, while probably well-intentioned, has misled you. Depression is a complicated group of disorders, and without proper training and a detailed interview no one can properly diagnose depression nor properly rule it out. When I say "group of disorders," I mean that depression is not, as some people mistakenly imagine, one simple ailment which will respond to one type of treatment. There are various forms of depression which have different origins, and good treatment for one form of depression might be useless or even harmful treatment for another.
I see various forms of depression as falling into five separate categories, each of which must be understood and treated differently. There is social depression which can result from isolation and lack of social connection. There is psychological depression which may have roots in early childhood experiences which were overwhelmingly painful. There is physical depression which may result from congenital abnormalities in brain chemistry. There is existential depression which arises when the usual motivators in life (sex and other forms of pleasure, money, power, fame, good works, etc.) seem, in the face of ones eventual demise, insignificant, so that the depressed person finds no meaning in existence ("I am going to die anyway, so what's the use?"). Or, if the person had been depending upon the idea of an afterlife to bring meaning to a life that seems to end in nothingness, he or she might feel depressed if serious doubts about those religious ideas begin to surface. If existential issues are the roots of a depression, it would be wrong to prescribe an antidepressant. That would only paper over the problem. A proper treatment would have to be philosophical,, not chemical. Finally, there is what I would call "spiritual depression," which sometimes precedes a spiritual awakening of some kind. If the depressed person is in that condition, he or she does not really need psychotherapy as much as the advice of a spiritual teacher who is awakened him or herself. Unfortunately, even some otherwise qualified psychologists--and particularly psychiatrists--fail to understand the meaning of these two latter forms, and so fail properly to meet the needs of patients for philosophical and personal understanding, instead dosing them with chemicals which may do more harm than good. In fact, I know some doctors who do not even believe that such a thing as spiritual awakening exists at all. Someone like that, who denies to himself or herself an entire realm of human experience, is especially likely to mishandle a case of spiritual depression, and all the more likely to dose the suffer with antidepressants which are certain to do more harm than good.
If you suspect that you are suffering from depression, it is important to seek professional help as soon as possible. I say "as soon as possible," because some types of depression worsen quickly without appropriate treatment, and depression itself may damage the brain in ways which are still mysterious. A recent audio program called Depression in the Brain, details some of the lastest research in this direction. If the sadness or other symptoms are accompanied by ongoing feelings that life is not worth living, which may be a form of suicidal ideation, seeking help is particularly urgent.
Your friend misled you in another way too. Even if medication is indicated, depression should never be treated with antidepressants alone. Numerous studies suggest, and all of my responsible colleagues agree, that any chemical treatment must be combined with psychotherapeutic counseling in order to produce optimal results in treating depression, and that psychotherapy is the first step, not medication. So even if you had responded in some way to the Zoloft, you would still not have been receiving the proper treatment. This is because deficiencies in brain chemistry usually do not cause depression as many people believe. Such deficiencies in brain chemistry are just as likely to be the results of previous mistreatment, abuse, and other real life experiences which damage the brain, and alter its chemical balance, resulting in depressed thinking. This common misunderstanding (a version of the old question: "which came first the chicken or the egg?") produces a world of confusion in the popular attitudes towards depression which, these days, imagine that depression can be cured simply by taking pills.
To repeat this important point: proper treatment of depression begins with a psychotherapeutic interview. Then, if medication is necessary, it will be accompanied by counseling aimed at improving point of view. If a physician tries to prescribe antidepressant medication without also suggesting some form of professional counseling, as some unfortunately are doing these days, in my opinion you should find a new doctor.
If you suspect that you may be depressed, a good first step would be to fill out a Center for Epidemiologic Studies Depression Scale, which, based on self-reported answers to twenty simple questions, can indicate if depression is present or not, or the Goldberg Depression Questionnaire, another self-test inventory questionaire, which is also available here, at the PsychCentral website, which has rated and reviewed ask dr-robert. Another useful depression self asssessment is available from the Mayo Clinic website.
If you score low on these, you may feel fairly confident that you are not severely depressed. But, if your score is not low, and if life has felt unsatisfactory for a prolonged time, and continues to feel that way, I would suggest an interview with a trained psychotherapist (not a new-age kind of counselor, nor a "guru," and certainly not a well-meaning friend). Such an interview, which should not require more than a single meeting, ought to be able either to diagnose depression or rule it out. In addition, even if depression is ruled out, such an interview could prove to be the starting point for a course of therapy aimed at improving your perspective on the value and possibilities of this often-challenging experience we call "life."
You will also find useful information on depression at the Healthline.com website. This page was suggested by a visitor to my website, and is well worth checking out.
I cannot leave this topic without addressing your friend's having shared her medication with you. That was not a good idea. Zoloft is not aspirin, and fooling around with brain chemistry is not a joke. I know that here in Mexico such medicines often are readily available without a prescription, but that does not mean they are safe to use without proper medical supervision, including a complete physical exam prior to beginning the medication. I hope you will understand this take it to heart.