Depression from Within
Endogenous Depression
No one, to my knowledge, is depressed at the point of birth even through, as a mental health condition, Major Depressive Disorder (MDD) has been identified in very young children including toddlers and infants. The environment at or near birth can certainly be a risk factor for depression. It can be hostile, essential attachment with one’s primary caregiver may be severed or simply not exist at birth. This can cause depressive-like symptoms.
NonOrganic Failure To Thrive (NOFTT) occurs in children younger than 2 years. There is no specific medical condition for NOFTT, even though not thriving has been associated with the earliest manifestations of infant depression.
There is evidence that infants deprived of attachment in early years are at risk for NOFTT depression, but it remains unknown if depression begins when life begins at birth.
I provide this introduction to suggest that the features of our world (or ourselves) can certainly create depressive symptoms. These include the environment and our internal body (or brain) chemistry. Pharmacology is based on the idea that depressive symptoms can be alleviated with drug agents that alter brain chemistry.
Endogenous Depression: People are born with an underlying genetic structure or a biological disposition, such as temperament, that puts them at risk for depressive symptoms. Frequently, a client will say to me:
“I have no idea why I’m feeling so low, Doctor, I’ve got a good job, my spouse loves me, my children are well behaved, I’m living by all accounts, a successful life. Why am I feeling so blue? So unhappy? Why do I feel worthless? Why do I want to escape my life by suicide?”
When someone presents this kind of story I wonder about the source of the depressive symptoms. My next step with a person who expresses these kinds of complaints is to take a life history.
Life History Questions
What are your earliest childhood memories?
Do you ever recall in your childhood or teenage years feeling down, lost, or that life was not worth living?
Did your emotions in your childhood or teenage years influence your decisions about things like your schooling (Where [or if] you went to college, What kind of jobs you worked at, Whether you felt liked or disliked by friends, What kinds of groups or clubs you belonged to or whether you isolated yourself).
Were you ever in counseling for your mood or attitude?
Did you ever feel traumatized by something that you think now should have not been traumatic (e g., going swimming, jumping off the diving board, going on a trip that you were fearful of the outcome, getting in a verbal argument with a parent or sibling).
The story of endogenous depression has a biological/genetic theme. Endogenous depression is difficult to understand and to treat. Many of our tools: Cognitive Behavioral Reframing or Increasing Positive Life Events. Acceptance Commitment Therapy to name a few are useful but they do not in-and-of-themselves provide permanent relief for a person with endogenous depression.
Weathering depressive symptoms is helpful, but this can be a long slog. Certainly, endogenously generated depressive symptoms change. They get better, then they get worse. Environmental factors impact endogenous symptoms. For example, when you isolate yourself it makes it hard for others to interact with you and you feel alone as a consequence. But, even after reconnecting with other people, endogenous symptoms may still persist and you feel like an outcast, like others are better off than you are. You lack motivation, you feel worthless, helpless, and hopeless.
What to do about Endogenous Depression?
Sarah and Endogenous Depression
Sarah was referred to me by a treating psychiatrist. A 40 year old single White female, she was looking for a therapist to help her get out of a low mood state that had been in place for almost a year. Her history was one that would not suggest depression. She was born in a tight-knit family. She described her parents as “loving” and reported that the parents’ marriage was good. She never observed her parents fighting or arguing, although they had disagreements between themselves. She had one sister, Janet, who was three-years older. Janet was married, had four children, a supportive spouse. Sarah and Janet were close. In high school, Sarah was active and enjoyed it. She was a Cheerleader, played tennis, had friends. It was difficult for her to make the transition to College, but she did so reluctantly. She majored in computer science. Did well in this academic area. She got a job in a large high technology firm and seemed for a while content with her work. She really had no desire to marry. Enjoyed being single, unmarried, professionally focused.
In her mid-30’s she began feeling bored and discontent with life. I asked her if she could recall any event or circumstances that were connected to her change in mood, but she seemed unable to do so. Her affect deteriorated and it started getting harder for her to work. She began working more hours at home. She started comparing herself to others and felt like she was always an outsider looking in. She believe that most people felt happier and more content than her. Her mood continued to drop and about three months prior to seeing me she started to wonder whether life was worth living. Her low mood seemed ironic to her. She really had nothing in her life that was going in the negative direction, no real worries. Her low moods became oppressive and debilitating. She started spending more time with her parents because she felt a little more at ease in her home of origin.
The intervention program began with cognitive behavioral strategies to help identify and challenge her thinking which we presumed was connected to her low mood states. She understood these exercises, they helped, but they did not impact her day-to-day mood state.
Her psychiatrist had started her on a regimen of fluoxetine (Prozac), starting at 20mg per day and progressively increasing this to 40, 60, 80, and then 120mg. We were tracking her mood while this first drug trial was underway, but it seemed that she was still depressed. The drug appeared to have limited or no impact on her mood state.
She wasn’t responsive to this drug, so he attempted another, lamitrogine (lamictal). This had better results. He started at 25mg and then increased the dose. At about 100mg/day, Sarah reported some mood shifting in the positive direction. This remained in place for about three months, but soon, her mood dropped again and it seemed that the drug, if it had had an impact, it was short lived.
The psychiatrist suggested Electro-Convulsive-Therapy (ECT), but Sarah was fearful of this procedure because she worried that it might permanently impact her memory.
Sarah and I spent considerable time discussing ECT and evaluating its pros and cons.
ECT (Electro Convulsive Therapy)
ECT has been around for a long time. Some historians suggest that it was started in the late 1930’s as a strategy to induce seizures in persons with mental illness including depression. It seemed that people who were depressed and had seizure disorder would experience relief of depressive symptoms following a seizure. The thought was that if a seizure could be induced, then this might create a treatment for depressive affect. Although there is controversy around how ECT was employed and for what purposes by the 1960s it was well established that ECT did improve depressive symptoms.
In my next entry, I will describe ECT in more detail, What it is and How it works.
Sarah did ultimately consent to a course of ECT treatment and it did have a positive impact on her mood. I saw Sarah for almost 10 years and during this time I observed her long struggle with adult depression; that is, depressive symptoms that appeared in adulthood.
It seemed that her depressive condition, once it appeared, ebbed and flowed with time. There were periods of years when she was depression-free, but then there were years when she was burdened by negative mood state. Over this long period it did seem, however, she adapted to the symptoms and made accommodations in her lifestyle that helped her function in the presence of depressive episodes.
Sarah ultimately, married, had children, remained at her professional career and became successful as a computer specialist in her technological area of expertise. She had three very difficult depressive phases and for these she enlisted ECT. The remainder of the the time, she found a drug therapy helpful, and she engaged in this on and off. When she had children, while she was pregnant and during the birthing process she took herself off drugs. She did not experience post-partum depression per se, although she worried this might occur.
It is important here to note that post-partum depression is not necessarily endogenous depression. Post-partum depression is a complex phenomenon that involves the interaction of external and internal factors that occur during the focal trauma of birth followed by the early adjustments in identity that occur in new mothering and parenting.
In Sarah’s case, close monitoring by a mental health professional, cognitive behavioral therapy to work on her thinking patterns when she was depressed, and strategic drug therapy combined with ECT became her way of weathering this disorder.
This vignette may raise more questions than answers.
Questions
What is the biological pathway of endogenous depression and how is it different from exogenous depression?
How does drug therapy work?
What are the active elements that work in Cognitive Behavioral Therapy?
What is the actual process and action of ECT?
These questions will be covered in further blog entries.