Understanding Depression: Causes, Symptoms, and Pathways to Recovery

Depression is one of the most prevalent mental health disorders. According to the World Health Organisation (WHO) about two 80 million people globally are diagnosed with depression, which is about 5% of the adult population. And in India, about 57 million people are affected by depression. Depression can be characterised by constant feelings of sadness, feeling low, hopelessness or loss of interest in previously enjoyable activities. Depression can significantly affect individuals’ occupational and interpersonal life and their daily functioning. It can create hindrances in self-care, and people may lack interest in hygiene activities. Is this not due to them being “lazy” but rather the manifestations of depression? They tend to lose interest in self-care activities due to a lack of energy, feeling exhausted, overwhelming feelings of worthlessness or pains or aches which are often the physical manifestations of depression.

Depression is not similar to regular affect changes or simply feeling low. It tends to persist for a longer period and also tends to penetrate every area of an individual‘s life. It can affect the individual’s quality of life and their ability to function adequately in life. Depression is about 50% more common in women as compared to men. Even though there are well-developed effective treatments for depression and other mental health disorders, most people in India are hesitant to seek professional help for it due to the social stigma associated with it. This disproportionately tends to affect men more. Due to cultural and societal norms, men are more hesitant to seek professional help when they are dealing with mental health disorders or depression.

Symptoms of Depression

In a depressive episode an individual might experience a low or sad mood, they might feel empty or irritable sometimes. One of the quintessential characteristics of depression is a loss of pleasure or interest in activities. Depressive episodes mainly last for two weeks with the individual experiencing mood fluctuations almost daily.

Other behavioural and cognitive symptoms are also present. Such as individuals might experience difficulty in concentrating on even simple tasks, might experience feelings of excessive guilt or low self-esteem and might feel hopeless about the future. Most of the time individuals also have thoughts about suicide or dying. They also tend to experience sleep disturbances, often having difficulties either falling asleep or poor quality of sleep. They also experience certain behavioural changes such as always feeling fatigued or low energy and also notice changes in their appetite. People going through depressive episodes might eat a lot or not eat at all, which leads to weight fluctuations.

Depressive episodes can range from mild, moderate or severe, depending on the severity of symptoms and how it affects the individual’s everyday functioning. There is also a pattern to these depressive episodes. One might experience single-episode depressive disorder in which that particular depressive episode is the individual’s first and only episode. Second, recurrent depressive disorder, means that a person might experience at least two or more depressive episodes.

Third, the individual might experience depressive episodes alternative to periods of manic episodes. During these manic episodes, people might feel an increase in activity or energy, an increase in self-esteem, and a decreased need for sleep. This is categorised as bipolar disorder.

Types of Depression

Depression can also manifest in several forms. Different forms of depression include:

Major Depressive Disorder (MDD)

Major Depressive Disorder is characterised by persistent low mood, loss of interest or pleasure in daily activities and significant disturbances in appetite, sleep and energy. In order to meet the criteria for MDD, the symptoms must be persistent for two weeks. During this depressive episode, the individual experiences feelings of excessive guilt, hopelessness and worthlessness. Again, MDD episodes can range from mild to severe, depending on the intensity of the symptoms and how they affect the person’s functionality.

Persistent Depressive Disorder (DYSTHYMIA)

Persistent Depressive Disorder is a more chronic form of depression, which is characterised by experiencing depressive episodes, which last for at least two years. The symptoms of dysthymia are less severe, but they are more chronic in duration. Hence it often has a worse prognosis as compared to MDD. A person with PDD might also experience episodes of MDD, which is referred to as double depression. Even though it is not as intense as MDD, it still significantly impacts the individual’s life due to its chronic nature.

Bipolar Disorder

Bipolar Disorder is characterised by alternating between periods of mania which includes high energy, feeling euphoric and episodes of depression, which are characterised by low mood fatigue. During the depressive episode, individuals experience similar symptoms to those of MDD. And during a manic episode, the individual might feel intense energy, increased activity or impulsivity. During the manic episode, the individual tends to be talkative and experiences racing thoughts, and engages in impulsive and reckless behaviour. Bipolar disorder tends to be cyclic in nature where depressive episodes alternate with manic or hypomanic episodes. These mood swings can vary in duration and intensity, with periods of elevated mood (mania or hypomania) followed by periods of deep depression.

Postpartum Depression

Postpartum Depression tends to affect about 13 to 19% of new mothers. Postpartum depression and baby blues are not similar, there are some notable differences between them. Baby blues tend to be short in its time span and it causes a less severe form of emotional distress. It can cause anxiety, disturbances, intense weeping etc. The postpartum blues affects about 80% of the new mothers. Whereas, Postpartum depression includes symptoms including persistent sorrow or low mood, trouble in focus, feelings of worthlessness, and overwhelming guilt, Anhedonia (which refers to the inability to experience pleasure), and difficulties in sleep, such as insomnia or hypersomnia.

According to the Diagnostic and Statistical Manual for Mental Disorders (DSM 5), postpartum depression typically appears during the beginning of the pregnancy or within the first month of postpartum. According to the International Classification of Diseases (ICD-10), postpartum depression can be diagnosed within the first six weeks of the postpartum period.

There are various psychological risk factors which can increase your susceptibility to postpartum depression. If you have experienced poor marital relations, lack of social support, loss of self-esteem and excessive stress due to life experiences, you may be at a higher risk for developing postpartum depression as these factors are strongly associated with PPD. Experiencing depression and anxiety during pregnancies, and having a history of depression and neuroticism can also increase your risk for developing postpartum depression.

Seasonal Affective Disorder (SAD)

Seasonal Affective Disorder (SAD) is not a distinct diagnostic category in DSM 5, but rather it is considered as a type of recurring major depressive episode with a seasonal pattern. SAD or seasonal affective disorder tends to have a seasonal pattern meaning that the depressive episode or feelings of depression tend to start and end during a specific season every year for at least two years and the individual experiences more seasons with depression as compared to seasons without depression over the lifetime. Seasonal pattern of depression tends to occur more frequently in winter and tends to show full remission during summers.

The question is what causes such a seasonal pattern of depression? Various resources show that dysregulation in the neurotransmitter serotonin might be responsible for mood regulation. People with SAD tend to have 5% more SERT in winter in summer. SERT is a type of protein which tends to facilitate serotonin transportation. They also tend to experience oversynthesis of melatonin. People with SAD over-synthesise melatonin throughout the winter compared to the summer. This leads to feelings of lethargy or increased sleepiness. Other studies also show that people with SAD might produce less amount of vitamin D, which tends to play a role in the serotonin activity. Even though the causal link between serotonin, melatonin, vitamin D and SAD has not produced consistent results, these associations are present and warrant further research.

Causes or Dynamics of Depression

Several factors ranging from genetic factors, neurotransmitter and psychosocial factors tend to play a role in the development of depression. The presence or the absence of certain factors can increase your risk of developing depression. That includes a few of these factors:

Genetics

Depression tends to run in the family, individuals with first-degree relatives with depression have a higher likelihood of developing depression as compared to individuals with second-degree relatives with depression. According to the twin studies genetics accounts for about 40 to 50% of variance to disorder. The concordance rate of depression for monozygotic twins is higher as compared to dyzygotic twins. This simply suggests a genetic vulnerability to depression.

Neurotransmitter Imbalance

Three neurotransmitters that are serotonin, dopamine and norepinephrine are implicated in the studies of depression. Serotonin is one of the most common and well-known neurotransmitters which is linked to depression. Serotonin plays a crucial function in mood control, sleep, and appetite. Low serotonin levels tend to contribute to the feeling of sadness, irritability and anxiety. Serotonin has also been linked to the regulation of pain perception, and individuals with low serotonin levels tend to be more sensitive to physical pain. Because of the connection between serotonin and depression, most of the medicines developed for the treatment of depression tend to target serotonin.

Dopamine is also one of the well-known neurotransmitters which are implicated in various research. Dopamine tends to play an important role in the feelings of pleasure, motivation and the brain’s reward system. Low levels of dopamine can lead to anhedonia, which is one of the most hallmark characteristics of depression. Various dopaminergic medications tend to target dopamine levels within the brain.

Norepinephrine, which is also known as noradrenaline, is involved in our bodies, fight or flight response. It helps us to regulate stress vigilance and our energy level. Low level of norepinephrine levels may lead to feelings of fatigue, apathy, and general sluggishness. Medicine such as serotonin-norepinephrine retake inhibitors tends to target, both serotonin and norepinephrine to reduce the symptoms of depression.

Environmental Factor

Stressful life events

Stressful life events, such as the death of a loved one, experiencing trauma, such as divorce, and financial problems can set the stage for depression. Especially people who have a genetic vulnerability to depression and who tend to experience these stressful events have a higher likelihood of developing full-blown episodes of depression. Certain health conditions such as heart, disease, diabetes or cancer are also associated with higher rates of depression. Managing the consequences of a long-term terminal in this as well as dealing with the physical and physiological symptoms of the condition tends to lead to higher feelings of hopelessness.

Social Isolation

Social isolation and loneliness also tend to contribute to feelings of depression. People who lack strong social support networks tend to be more vulnerable to developing depressive symptoms. This can also turn into a vicious cycle, individuals who experience depressive symptoms might withdraw from social interaction, hence leading to a lack of fulfilling social relationships and a lack of social networks. This intern increases the feelings of depression.

Cultural and Socioeconomic Factor

In some cultures, depression and mental health are stigmatised, hence, individuals experiencing these symptoms or experiencing mental health concerns do not seek any help. This might exacerbate there are symptoms. Additionally, people with lower socio-economic status tend to have a higher risk of developing depression due to a variety of factors. They are exposed to stressors such as job instability, housing insecurity, financial instability, and also poor access to healthcare and mental healthcare.

Treatments for Depression

Psychotherapy and pharmacotherapy are commonly used therapies for depression.

Cognitive Behavioural Therapy

CBT is one of the widely used and well-researched forms of psychotherapy for depression. Originally developed by Aaron Beck with an underlying assumption that depression is caused by negative thought patterns also known as cognitive distortions. Hence, CBT aims at identifying and challenging these distorted thinking patterns and replacing them with more adaptive and effective thought patterns.

Interpersonal Therapy

Interpersonal Therapy focuses on improving the individual’s relationship and communication skills as poor interpersonal relationships and functioning can be a cause and can worsen symptoms of depression as discussed above. It was initially developed by Gerald Klerma and Myrna Weissman, Interpersonal therapy is based on the assumption that our moods are often related to our life events. Hence, by addressing these interpersonal issues, individuals can improve their mood and reduce depressive symptoms.

Interpersonal therapy tends to focus on a wide array of aspects of our lives. It focuses on things such as grief and loss, and role transitions, such as marriage, divorce, retirement, or becoming a parent, it also focuses on interpersonal conflict, whether it is with a spouse, family, partner, colleague, etc. It also tends to focus on certain interpersonal deficits as well.

Some individuals might struggle with initiating and maintaining interpersonal relationships due to their anxiety or poor communication skills. Interpersonal therapy helps them to build better social skills in order to establish meaningful interpersonal relationships. All of these things in combination tend to improve, depressive symptoms.

Medications

Medications are often used for moderate to severe depressive symptoms. The medicines help to create and state of balance to the neurotransmitter imbalances in the brain. As the dopamine, serotonin, and norepinephrine neurotransmitter imbalances are implicated in depression, most of the medications target these. Selective serotonin reuptake inhibitors, such as Prozac and Zoloft are commonly prescribed as antidepressants.

They tend to increase the serotonin level in the brain, which improves mood and emotional regulation and also tends to improve sleep. They tend to be one of the most prescribed drugs because it is considered relatively safe and has fewer side effects than the older classes of antidepressants. Serotonin-norepinephrine reuptake inhibitors are frequently recommended for depression because they tend to target both norepinephrine and serotonin.

They tend to be very useful for individuals who experience symptoms such as fatigue and lack of motivation. Another class of drugs known as monoamine oxidation inhibitors are also used. Even though being rarely given due to severe negative effects and restrictions on diets. They are usually reserved for treatment-resistant depression.

Lifestyle Changes

Apart from therapies and medicines, individuals can also integrate certain lifestyle changes in order to aim for a more holistic treatment for depression. This includes improving your diet. Research shows that processed foods and sugars can increase the risk of depression. Hence, following a Mediterranean diet that includes many vegetables, lean protein and healthy fats can improve mood and reduce depressive symptoms.

Apart from this engaging in regular exercise can also increase the level of endorphins in the brain, which in turn improves sleep and also reduce stress. All these factors contribute to a reduction in depressive symptoms. Just 30 minutes of moderate exercise 3 to 5 times a week tends to improve the symptoms of depression. A lot of individuals also tend to benefit from integrating mindfulness and meditation practices. This can help to reduce the rumination and negative thought patterns which are often associated with depression. And the individual also tends to be more aware of their thoughts and emotions without any judgement.

Experimental Treatments

These treatment methods are not commonly used for all patients with depression. These treatments are often given to individuals with treatment-resistant depression. Ketamine therapy has shown effective results in individuals with depression. It is usually used as an anaesthetic, it tends to work on the brain’s glutamate systems and also restores the connection between brain cells. However, there are various sites such as dissociation, nausea, and vomiting, which increase blood pressure.

Even though ketamine tends to provide immediate relief to depressive symptoms, however, this relief can be temporary. Ketamine therapy is not often used as the clinical trials do not show any promising results. Moreover, the cost of administering ketamine therapy is also can also be relatively high and it is not universally available. Though it can be an effective treatment for depression. Still, it warrants for better research into it.

Conclusion

In essence, depression is a very complex mental health disorder, which affects millions of people in India and globally. Depression is caused by a diverse range of causes. Ranging from biological factor, such as genetics and neurochemical imbalances to psychological, social, and environmental factors. There are various effective therapies and treatments for depression, which includes psychotherapy medication, lifestyle changes and certain new and emerging therapies such as Ketamine therapy. These treatments are prescribed or administer on their own or sometimes in combination with each other, depending on the severity of the symptoms. Though research on the causes and the treatment of depression are widely available. There is a lack of awareness and access to mental health resources, specially in India. Creating awareness about mental health concerns and depression can lead to greater number of people seeking professional help and social support.