Frequently Asked Questions About Major Depression
Mark Vakkur, M.D.
What is major depression and how is it different from sadness? Don't we all get depressed?
Major depression is a serious, potentially life threatening illness. We may all get sad from time to time, but researchers estimate that only about 15% of Americans ever develop major depression. Major depression is a constellation of symptoms. Perhaps the simplest way to think of major depression is as a profound disturbance in multiple drives: the drive to seek new experiences, to interact with others, to eat, to have sex, to sleep, and ultimately to live. People who have major depression often suffer from decreased concentration, appetite, sleep, and energy. They may find things that used to give them pleasure no longer do (anhedonia), or feel that even if they could enjoy things, they have no energy to do them. Although they often sleep poorly, they wake up feeling tired and miserable. Guilt is very common. They may be tearful, and may consider suicide.
This sounds pretty subjective. How can you say with such certainty that someone is depressed or not?
There are a few biological markers of depression, but they are not practical for everyday use. Major depression remains a clinical diagnosis, meaning that a clinician must take a detailed history and make a determination based on the presence or absence of certain clinical criteria. Some of these may be things that the patient reports, but others may be things that the clinician observes (such as facial expression, slowed or agitated movements, and themes of doom and gloom pervading the patient's speech).
The overall pattern is what is important. Clusters of symptoms that tend to run together. Over the years, researchers and clinicians have developed some very good tools to assess depression. Some are scored by the clinician, others by the patient, some by a combination. All are very reliable, meaning two different clinicians are likely to arrive at the same diagnosis, and valid, meaning that when the diagnosis is made using the test it tends to match some gold standard.
For a quick and dirty screening tool, we sometimes use an acronym, SIGECAPS:
Give yourself one point in any of these is currently true for you. Total the points; if your score is 4, you may be depressed. If your score is 5 or more and your symptoms lasted for at least 2 weeks, you have depression until proven otherwise.
Most of those who develop major depression do not get any treatment. Although most people with major depression do not commit suicide,
What is the underlying cause of depression and anxiety?
That is an excellent question. I think it is important to keep an open mind about the causes of various disorders. We assume, sometimes with good reason, that various life events, or our ability to cope with them, "cause" depression or various other conditions. However, there is plenty of evidence that depression has a very strong genetic component - even if adopted away daughters of depressed (birth) mothers in one study had significantly higher rates of depression than adopted away daughters of non-depressed mothers, even though neither group had any contact with their depressed mothers. Despite racism and poverty, African Americans have a suicide rate only half that of white Americans. Studies in Europe showed that suicide rates were lower during World War II and the Holocaust than they were in the postwar years. Clearly there's a lot more to depression that we understand. The idea that all or even most oppression is caused by stress or loss is simply not supported by scientific evidence. Although severe stressors such as sexual or physical assault or the loss of a job or freedom can predispose to depression, many people who experience these events do not develop major depression, and most people who develop major depression have not experienced catastrophic psychosocial stressors.
The nature-versus-nurture will continue to rage, but it seems most likely that the causes of depression or any mood disorder are complex and multifactorial. A combination of genetic endowment, coping strategies, life events, and critical relationships seems to determine who gets depressed and who doesn't.