Clinical Depression (Part 1 of 3)
Major Depressive Disorder (MDD): Identifying, Treating, Ameliorating
Today: December 30, 2023.
Bob’s Substack Blog:
I’ve written- since 2020 - over “100” entries.
Readership by entry varies from 11 to over 1,000.
Why?
I don’t charge dollars to read this blog, although people do send me money from time to time, and with this I pay for blog upkeep.
Readers value tough entries, Suicide (over 1,000), Death (700), Bipolar Disorder (close to 1,000), and Borderline Personality Disorder (200+).
Entries rarely opened by readers are: Lust (11 readers), Emotional Turbulence, UFO Psychology (less than 20 readers).
Readers appear to want real issues, not philosophizing about the unexplainable (Dreams, UFOs, Tarot Cards, and such). However,
Last month, I bought A deck of Tarot Cards.
Are Tarot Cards linked to improved mental health?
I’ve trained myself to do readings. Getting good at it.
Testing an idea: Is discerning the future important? If so, Why?
My Tarot deck is small. Sits on a shelf in my waiting room, and people ask if I do “Readings”.
Why?
Perhaps they think I’m a psychic.
That’s not what a Psychologist does. Or is it?
Can a Tarot Card reading change your life?
I think the key to changing a way of life is a “Paradigm Shift”. You can refer to this earlier entry. A “Paradigm Shift” is powerful but also elusive.
Example: A man in SF, CA jumps off Golden Gate Bridge and somehow survives.
San Francisco's Golden Gate Bridge suicide safety net will give many a 2nd chance at life, survivors say | CNN, Mon August 12, 2019
This man says he’s no longer suicidal, now he’s devoting himself to helping people who feel suicidal.
He reports a “paradigm shift” (of sorts), in his mood/mental health/and thinking. The cost, taking an enormous risk.
I do NOT recommend this (or anything resembling it). The man in this report should be dead. But, a survivor he is, no longer suicidal. Or so he says.
Recall my entry on “suicide motivation,” and the story of the teen (now older adult) who jumped from a six-story building. As he leaped over the threshold, the first thing that went through his mind was: “I made a big MISTAKE.” He survived and reported to me - many years later - that he was no longer (and would never be) suicidal again. He did pay for this “enlightenment” for the rest of his life (read blog entry for details), but still, it seems a paradigm shift took place here.
How does a Paradigm Shift work
Some religions preach paradigm shift. They say, Be “Born Again”. This will change your life, and, for some, perhaps it does.
BUT, What is “Born Again?”
Is it A Paradigm Shift?
People profess that being “Born Again” is becoming a different person.
Even so, Now who are you?
Sometimes Paradigm Shifts are subtle. Example: Siddharta,
I call this a “Developmental Paradigm Shift.” And, I have a blog entry on it.
Hermann Hesse wrote, Siddhartha, in 1922. The novel describes what Hesse envisioned as the spiritual self-discovery journey of a “wealthy” teen-to-man. In his teens, Siddhartha gets into his head that he is “unfulfilled.” His life lacks meaning, and living is drudgery, although he is guaranteed the comforts of a wealthy man. After fighting with his parents, mostly his father, about his issue, Siddhartha starts a journey. First, as an ascetic (the poorest class in India), then he becomes a wandering beggar. He’s joined by a friend, Govinda, and they wander together. They fast, give up every pleasure, are homeless, renounce all personal possessions, meditate profusely, and start speaking with Gautama or the Buddha (who is at this time, living). Govinda eventually joins the Buddha's order, but Siddhartha - this is where Siddhartha and Govinda separate - argues that the Buddha’s way does not account for the uniquely distinct experiences of each person. Siddharta, instead, pushes on for a unique, personal meaning experience that he believes cannot be taught by a Teacher or Guide. The story goes on as Siddharta wanders, lives, suffers, makes mistakes, and learns (individually) from external experience and internal promptings. It’s a story, like life, with twists. In the end, Govinda searches out and finds his “very old” friend Siddhartha who is alone managing an isolated Ferry crossing for a nameless river - for a time, Siddharta had a son, but the son left him. At nearly the end of his natural life, Siddharta realizes that:
“…time is an illusion and that all of his feelings and experiences, even those of suffering and happiness, are part of a great and ultimate “fellowship of all things” connected, somehow, in the cyclical unity of nature…”
Govinda asks:
What have you learned?
Siddharta responds:
For every “[t]rue” statement there is an opposite one that is also “[t]rue”; that language and the confines of time lead people to adhere to mostly one fixed belief and this does not account for the fullness of the “[t]ruth”.
Nature (many words can be substituted for Nature; the universe, God, Yahweh, Allah, etc.) works in a self-sustaining cycle, every entity carries in it the potential for its opposite and so the world must always be considered complete. People should identify and love the world in its completeness.
“Govinda” leaves Siddhartha, but is aware that Siddharta has found enlightenment (Siddharta is now one with Nature). Perhaps Govinda experienced a developmental Paradigm Shift as well. If so, the paradigm shift started “internally” for Siddharta and “externally” for Govinda (who followed Siddharta).
A novel, so “truth”, if there is any, is embedded in what we want to give it.
My view is that Psychology has yet to figure out a “paradigm shift”.
But, if it could? Here would be a powerful intervention!
Could a Tarot Card Reading create a Paradigm Shift?
Your guess is as good as mine.
The most frequent client issue I confront daily in my practice is:
CLINICAL DEPRESSION
By this I mean the personal intra-psychic experience of low-transient to persistent mood with devastatingly deep dysphoria that feels (and is) negatively overwhelming in severe intractable states.
Clinical Depression is life-altering and not in a positive way.
Libraries of academic and professional writing are devoted to clinical depression. The empirical, philosophical, physiological, neuropsychological, social, economic, biographical, and autobiographical information on clinical depression is bewilderingly large. Even for scholars and professionals, good information about the causes, course, treatments, and long-term implications of clinical depression is difficult, especially to translate into application.
This entry highlights the best fundamental knowledge available, (through 2023) about Clinical Depression.
What, as a society, do we:
Know about it.
Think we know about it.
DON’T know about it.
This includes: What it is (or what we think it is), How we treat it, and How to ameliorate a clinically depressed state.
WHAT IS DEPRESSION?
Depression is defined as: (condition): 1. the state of feeling very unhappy and without hope for the future: 2. a mental illness in which a person is very unhappy and anxious (= worried and nervous) for long periods and cannot have a normal life during these periods.
The American Psychological Association (APA) Dictionary defines depression as: (noun)
a negative affective state, ranging from unhappiness and discontent to an extreme feeling of sadness, pessimism, and despondency, that interferes with daily life. Various physical, cognitive, and social changes also tend to co-occur, including altered eating or sleeping habits, lack of energy or motivation, difficulty concentrating or making decisions, and withdrawal from social activities. It is symptomatic of a number of mental health disorders.
There is a proviso in the APA Dictionary for “Depressive Disorders” and I present this below: (updated 11/15/2023)
any of the mood disorders that typically have sadness or empty or irritable mood as the predominant symptom. In DSM-5 and DSM-5-TR, the category of depressive disorders includes major depressive disorder, dysthymic disorder, disruptive mood dysregulation disorder, persistent depressive disorder, premenstrual dysphoric disorder, substance/medication-induced depressive disorder, depressive disorder due to another medical condition, other specified depressive disorder, and unspecified depressive disorder
What we “know” about depression comes from what people who are depressed tell us, their state of mind, emotions, physical health, and their POV. We reason from such personal reports a framework of physiological and psychic dysregulation that shapes a depressed person’s POV. We do this by contrasting the physiological/psychological state of people who tell us they are depressed with those who tell us they are NOT depressed.
It boils down to what a person tells us about the person’s internal state of the person’s mind (using words), and by allusion, how the person describes the outside world as it appears to the person who is experiencing depression (POV), and what that person is willing to tell us about the person’s unique experience. Our main technique for doing this is to ask a person (who is clinically depressed) questions about the person’s mental and emotional state:
Patient: Dr. I feel depressed.
PCP Dr (question). Can you tell me more specifically what you mean by this?
Patient: Depressed. My “mood” is low, and I have no motivation (the patient is now tearful). I feel like crying all the time, I feel I’m carrying a big weight on my shoulders. I’ve lost my interest in food, in sex, in talking with others. I want to withdraw from everyone and everything, I have thoughts of harming myself, even killing myself because I can’t bear this emotional pain any longer. I feel guilty all the time even though I’ve done nothing wrong, I envy others who feel OK even happy, I can’t sleep because I can’t stop thinking negative thoughts, my mind races around, but I have no motivation to act on my thoughts. Sometimes I feel dead inside. I can’t concentrate, I feel internally agitated, I’ve lost hope in the future., and so on.
[CAVEAT: It is unlikely a person who is depressed feels all these issues simultaneously, rather, this patient description above seems to combine historical feelings (not currently felt), current feelings (felt), and possibly future feelings that the person conjectures he or she “might” feel (fear-to-be-felt). This description might seem misleading, but fear is embedded in it; fear that a symptom might return and fear that a new symptom might arise (not yet felt). This is an unstated, but common feature of a fear-based, dysregulated, state of mind (depression or NOT).
PCP Dr. (question): How long have you felt this way?
Patient: I’ve felt this way for a long time, I can’t remember when I felt what you might call good, that is, if I ever did, but I know it has been at least a year that I’ve felt this bad. I don’t think I will ever feel good.
PCP Dr. (question) Have you tried to do anything to improve your depressed state of mind?
Patient: Dr. I’m so depressed and unmotivated, all I do is sit at home all day and stare at the television. I don’t even watch what’s on. I just sit there in a state of misery. No hope of getting better, and I have no energy to try to get better, I just sit there in a lost but restless state, as I watch the clock tick and I experience every second of every minute of every hour of every day of my life in misery. No, I have not tried anything.
PCP Dr. (writing/typing out a prescription for Fluoxetine (Prozac): Mr/Ms/Mrs/M XXXX my judgment is you are experiencing clinical depression. (question) Would you be willing to try this? I’m glad you’ve come in today because there are things we can do that will help you feel better.
Patient: Thank you.
PCP Dr. I’m writing a referral for you to start seeing a Mental Health Provider. Here is the contact information. Would you be willing to follow up with this person as soon as possible?
People, over time (with or without drugs or therapy, including transcranial therapies, ECT, Hospitalization, tailored drugs, psychotherapies of all types, and so on) go positive and negative over time in how they describe their depressed state. This is from moment to moment, day to day, week to week, month to month, and so on. This can be for a short time or sometimes a long while. Eventually, people learn to live with their depressed state, perhaps they adapt, become simply resigned to their state of mind, or accommodate here and there, or maybe they simply start feeling better, but most keep going on with their lives in the presence (or intermittent presence) of a clinically depressed state of mind.
Clinical Depression, for the most part, is a chronic condition, so if it diminishes for a while that’s NO guarantee it won’t return, in fact, it usually does.
Describing a depressed state of mind has also been codified into systematically written statements (or questions) that a person completes via paper pencil, orally, via the internet, etc. These are called measurement instruments, tests, checklists, surveys, whatever you want to call them.
Professionals employ these instruments to verify that a description fits the framework of what WE, as professionals, believe is a clinically depressed condition. These instruments are created by PROFESSIONALS (not the depressed person) and are frequently used to gauge the severity, chronicity, and debilitating power of a given depressed condition or a depressed state of mind in an individual client or patient.
Below is a simple Measurement Instrument for Depression called the Zung Depression Scale (Zung is the name of the researcher who developed it and who published it in 1965; still used today).
The Zung Self-Rating Depression Scale is a short self-administered survey to quantify the depressed status of a patient. There are 20 items on the scale that rate the four common characteristics of depression: the pervasive effect, the physiological equivalents, other disturbances, and psychomotor activities. There are ten positively worded and ten negatively worded questions. Each question is scored on a scale of 1-4
a little of the time
some of the time
good part of the time
most of the time.
For each item below, please record a score between 1 and 4 for the description that best fits how often you felt or behaved this way during the past several days.
I feel downhearted and blue.
A little of the time Some of the time Good part of the time Most of the time
Morning is when I feel the best.
Most of the time Good part of the time Some of the time A little of the time
I have crying spells or feel like it.
A little of the time Some of the time Good part of the time Most of the time
I have trouble sleeping at night.
A little of the time Some of the time Good part of the time Most of the time
I eat as much as I used to.
Most of the time Good part of the time Some of the time A little of the time
I still enjoy sex.
Most of the time Good part of the time Some of the time A little of the time
I notice I am losing weight.
Most of the time Good part of the time Some of the time A little of the time
I have trouble with constipation.
A little of the time Some of the time Good part of the time Most of the time
My heart beats faster than usual.
A little of the time Some of the time Good part of the time Most of the time
I get tired for no reason.
A little of the time Some of the time Good part of the time Most of the time
11. My mind is as clear as it used to be.
Most of the time Good part of the time Some of the time A little of the time
I find it easy to do the things I used to.
Most of the time Good part of the time Some of the time A little of the time
I am restless and can’t keep still.
A little of the time Some of the time Good part of the time Most of the time
I feel hopeful about the future.
Most of the time Good part of the time Some of the time A little of the time
I am more irritable than usual.
A little of the time Some of the time Good part of the time Most of the time
I find it easy to make decisions.
Most of the time Good part of the time Some of the time A little of the time
I feel that I am useful and needed.
Most of the time Good part of the time Some of the time A little of the time
My life is pretty full.
Most of the time Good part of the time Some of the time A little of the time
I notice I am losing weight.
A little of the time Some of the time Good part of the time Most of the time
I still enjoy the things I used to do.
Most of the time Good part of the time Some of the time A little of the time
END
Scoring the ZUNG: Each question is scored on a scale of 1-4 (a little of the time/some of the time/ good part of the time/most of the time). The standard “block” statements are scored 1 through 4; The “italics” statements are scored 4 through 1. Add the scores to get a SUM or maximum score.
25-49 Normal Range
50-59 Mildly Depressed
60-69 Moderately Depressed
70 and above Severely Depressed
Zung, WW (1965) A self-rating depression scale. Arch Gen Psychiatry 12, 63-70.
__________________________
There are over 350 depression instruments (like the Zung, 1965). All of them assess psychological state (what people tell professionals about their depressed state). I’ve listed most below. I’m listing them because I want to discuss what this WHOLE list means especially for a person experiencing clinical depression.
Mood and Outlook
Confidence and Self-Judgement
Sleeping, Waking, Daytime Sleepiness
Weight and Appetite
Fear, Panic, Anxiety
Self Harm, Suicide
Attention, Concentration, Mental Focus
Distress and Trauma
Energy (psychic) Level
Attachment and Affiliation, Interpersonal Relations
Restlessness and Impatience
Physiological reactivity and response
Activity Level and Talkativeness
Anger and Irritability
Planning and Decision-Making
Sexual Problems and Interest in Sex
Digestive problems
Emotional Lability
Self-Perception, Personal Awareness, Appearance
Avoidance and Self-Preoccupation
Mind Wandering and Delusions
Memory and Forgetting
Rigidity
Obsessions and Compulsions
Health Worries
Muscular Complaints
Learning and Development Difficulties
Aches and Pains
Defiance and Disobedience
Self Control and Emotional Regulation
Guilt and Shame
Obsessive Worry
Longing to feel better
WOW! WHAT A LIST!
Must a depressed person describe all these to be classified as Clinically Depressed? NO
But, people who say that they are depressed will describe groupings of these issues and the groupings may change over time. These fall into three categories:
Mood
Mental or Cognitive Abilities
Motivation
I’ve spent more than two decades studying (writing about) these issues in people who say they are depressed.
People who say they are NOT depressed also experience some (or all) of these issues, but they would not be diagnosed with depression per se. Everyone, myself included, feels a blue mood from time to time. Lots of people feel guilt, from time to time, sometimes over nothing. Many people feel a sense of longing, for example, after the break-up of a love relationship. Many people feel like total failures once in a while. Lots of people, especially those who have lost a loved one to death, feel that their positive outlook no longer exists and will never come back. These people would not be clinically depressed per se., even though they may struggle with issues that warrant seeing a psychologist for depressed mood or depressed feelings. There is a subtle, but important distinction here.
How do you know if you are “clinically depressed” versus just going through a hard time, or just having a really bad day, or are suffering from the need to change a problematic behavior (like too much alcohol drinking) but delaying the inevitable, or you are in a really bad emotional slump and you don’t know why, or you are angry even with someone else and taking it out on yourself in the form of low mood, and despondency?
What is unique or special about Clinical Depression from all the other things in life that can impact your mood, motivation, or your mental state?
People who are clinically depressed also say that they feel “ANXIOUS”.
What’s the difference between TRUE CLINICAL DEPRESSION and generalized anxiety disorder or panic attack or social anxiousness, or ADD, or Obsessive-Compulsive disorder because these things can cause you to feel low mood, despondency, confusion, lack of interest as well?
There is a gigantic body of research that says that clinical depression is BIOLOGICAL versus PSYCHOLOGICAL. Perhaps clinical depression is both.
Which is it?
Biological, Psychological, or Both.
Does biology cause you to feel clinically depressed, OR does your psyche push your biology into a dysregulated state that then causes you to feel the characteristic state of clinical depression? (example: after some kind of physical trauma).
I’m guessing you have more questions than answers. In fact, you might be wondering if there are any answers out there to:
Knowing if you are experiencing a clinically depressed state of mind or NOT?
If there are any “good” strategies, assuming you are clinically depressed, for dealing with such an awful human condition.
Some people think animals are clinically depressed, dogs, cats, monkeys, mice, etc. To the best of our knowledge, this doesn’t seem to be the case, although you can teach an animal to act (and feel helpless), this isn’t clinical depression, per se. So the answer is, NO, animals don’t naturally acquire or express (verbally or otherwise) Clinical Depression.
There is bona fide help out there for this condition, even for the most debilitating and intractable forms of Clinical Depression. So, the answer to this is an unequivocal YES (but simply taking a pill won’t do it. It might help, but it won’t alter, 100% your clinically depressed state to a non-clinically-depressed state).
If YES TO HELP, What is this elusive HELP? If it exists, CAN I GET AT IT!
Hold on, it’s not that simple. It’s not like healing clinical depression is the same as healing a broken bone. Your body heals a broken bone, not your psyche per se. whether you are in a good state or not, whether you want it to heal or not Your body just does it, heals the bone. The broken bone analogy is not the story of healing in Clinical Depression.
Then, What is?
This is not an easy disorder to heal, but it is possible to heal (sometimes fully) from Clinical Depression.
Some additional features of Clinical Depression are essential to highlight:
It’s a process and course because Clinical Depression comes from within you and your reaction/responses to your world.
It operates predictably and people suffering from its dysregulatory consequences usually work against getting better, people tend to amplify depressive symptoms until they figure this out.
Clinical Depression is a disorder with a message embedded in it. It is your psyche speaking to you, expressing symptoms of something core, perhaps in a seemingly harsh and scary way, but speak to you it does! Deciphering its underlying causal features is useful.
Depression is as much a cultural phenomenon of our humanity as it is an internal biological dysregulation. You are benefitted from isolating what is at the origin-point of your own depressive symptoms. The psyche impacts biology. This is a FACT. So, clinical depression can originate in the psyche and move into biology (through dysregulation which means biological over- or under-compensation). Remember, the brain is “dynamic” not “static”, if it can adapt to circumstances, it can fail to adapt or it can damage itself due to circumstances, perceptions, POV.
Healing takes time, short of a Paradigm Shift, which I continue to work on because I think this is an underused healing pathway with substantial potential, but I have yet to figure out how to systematically make use of it; however, I’m getting there. I’ve got it to work a few times and when it has, Wow! Simple change can’t capture what occurs as a consequence.
I’ve exceeded the word limit. To segue into Part II, I will outline how to heal from Clinical Depression (at least the ways we know how in 2023). To do this, it is helpful to understand yourself at a much deeper level of psychic processing: 1. Who you are, 2. What this disorder is telling you about yourself, 3. A willingness to try a few new things, some paradoxical, to break out of the psychological box you are being held in. Sometimes it’s a metal box and sometimes it’s only a paper box, but a “box” it is and it is possible to get out of the box, for everyone inside.
I leave the remainder of this discussion for Part II.