Laval Families Magazine is bringing you the first of a new series on mental health. In this issue, we begin the discussion on depression with the first of three installments, taking an in-depth look at the complexity of clinical depression. Dr. Mary Tsonis, psychologist and founder of Your Psychology Clinic in Laval, answers Lori Leonard’s questions.

Q: We hear a lot about depression. What exactly is it?

A: Major or clinical depression is a serious mental illness classified as a “mood disorder”. It affects peoples’ mood, functioning and behaviour, their attitude and their thoughts. It often comes with an overwhelming sense of despair and hopelessness. True depression is not simply feeling down or sad, it is not feeling blue, or even grief. People often state“I’m so depressed” to express that they are feeling down. We all have moments, days or phases of sadness, but temporary cases of the blues have nothing to do with real or true clinical depression.

At any given time, almost three million Canadians have serious depression, but less than one third seek help. During their lifetime, five to twelve per cent of men and ten to 20 per cent of women will have at least ONE episode of major depressive disorder. Anxiety and depression account for 79% of all psychiatric diagnoses. The World Health Organization (WHO) predicts that by 2020, major depression will be second only to heart disease as the leading cause of disability worldwide.

Q: What are the symptoms of depression?

A: The symptoms of depression include: changes in sleep patterns (e.g. sleeping too much or too little), changes in appetite resulting in weight gain or loss, changes in activity level (e.g. being highly agitated or sluggish and inert), feeling despair, or extremely sad or very bad-tempered and irritable or both, crying spells or wanting to cry but not being able to, a loss of interest in the pleasures of life, as well as in work, family, and friends, poor concentration and inability to make decisions, feeling anxious, guilty or unworthy, fatigue and an overall loss of energy, feeling numb or a feeling of emptiness, and unexplained aches or pains.

A diagnosis of major depressive disorder is made when a person has at least five of these symptoms for a period of two weeks or more, and there are significant impairments in their ability to function at work, school, or socially. Some people with depression can also experience psychosis where their thinking is out of touch with reality.

Q: Are there different types of depression, or is it all generalized under one term?

A: There are different types of depression: Persistent Depressive Disorder (or Dysthymia), Postpartum Depression, Seasonal Affective Disorder (SAD), and Depression associated with Bipolar Disorder. While Postpartum Depression and SAD get a lot of media attention, Dysthymic Disorder is less well known but it is a form of depression where people experience “low mood” for a long time. They may still function adequately, that is, go to work and even run a business, run their household, etc...but struggle with lack of interest, poor appetite, insomnia, low self-esteem, and feelings of hopelessness. The symptoms can go on for years. People with Dysthymic Disorder come to believe that this is just the way they are. They may or may not have bouts of major depressive disorder. I once had a client, an intelligent woman, a successful entrepreneur and mother of teens, who said to me, “Mary, there are some people who wake up and even though it is raining outside, they feel the sun shine in their hearts. I have never felt that. I feel like it is raining all the time, even though the sun may be shining.” She just thought it was her “personality”.

Q: What causes depression?

A: There are many causes associated with clinical depression. One cause is genetics or family history, that is, depression runs in families so if close family members have experienced depression you may have an inherited tendency yourself. Temperament and personality, also determined by genetics to an important degree, also play a role. Those who are more pessimistic and negative in their interpretation of life events, less resilient to change, perfectionistic, and who lack a support network are at greater risk for depression.

Another causal source is situational, or life events. That is, a divorce, the death of a loved one, job loss, chronic illness, work or other family pressures. Your history may also contain “causal” factors. For instance, sexual, physical or emotional trauma in childhood or trauma in adulthood such as domestic abuse, rape, or witnessing a robbery or other act of violence. It is important to remember that often our physiology, or genetic makeup, interacts with life events and increases the chances or risks of a major depressive episode.

Given the higher rates of depression amongst women, hormones (associated with menstruation, childbirth, and menopause) are also thought to play a role. Depression is also strongly associated with medical illness and chronic disability.

Use of some prescription and non-prescription drugs can lead to depression by interfering with important brain neurotransmitters. Alcohol is a known central nervous system depressant and prolonged use is associated with a greater incidence of depression.

Q: Are there certain degrees of depression or certain illnesses related to depression?

A: Yes, depression occurs along a continuum from mild to life-threating. Milder episodes of depression may resolve with time, however more severe depression can last for years and without treatment can cause permanent disability. No amount of true grit, “being strong”, positive self-talk, love and support will lift the dark and oppressive cloud of depression. It is an illness and it needs to be treated.

Regarding illnesses and depression, it is important to understand that depression is both a predictor and an outcome of physical illness, or in other words, depression is a cause and a result of physical illness. Depression as a “cause” of physical illness is supported by studies showing that people with depression are 2.6 times more likely to have a stroke and about 1.5 times as likely to develop cancer. Research has also documented that depression is an outcome or result of certain illnesses; certain medical conditions affect mood and leave people feeling depressed. Simply living with illness, or chronic illness can also result in depression. People with physical illnesses such as stroke, diabetes, heart disease or cancer suffer depression in disproportionately higher numbers than the general population.

Finally, depression itself can present with, or is associated with, physical symptoms or true physical pain. Research is pointing towards shared neural pathways for pain and depression, with serotonin and norepinephrine being involved in both pain and mood. Many people who are depressed often talk to their doctors about their physical pain. Studies have shown that people who complain about unexplained physical symptoms are more likely to be suffering from depression, and of those reporting nine or more physical pain symptoms, 60% had a mood disorder. When only one physical pain symptom was reported, only 2% had a mood disorder. People who experience chronic pain when depressed as also more likely to have suicidal thoughts.

Q: Should someone seek care from their physician or from a psychiatrist or psychologist? Who is the right person to seek help from?

A: Family doctors, or general practitioners as well as psychiatrists take care of pharmacological treatment or management of depression. Psychiatrists are usually consulted, and are necessary, if the depression is severe and/or a person does not respond to the standard medication administered by a general practitioner. In addition, psychiatric consultation is necessary if the person presents with suicidal ideation or suicidal behaviour.

Psychologists, on the other hand, usually provide therapy for depression. Usually both avenues of treatment are advised, that is, both medication and therapy. Be sure to find a psychologist with experience in treating depression, who will regularly monitor how you are feeling on your meds, who is well-versed in psychopharmacology, and who is willing to collaborate in your care with your family doctor or psychiatrist. In addition, I firmly believe that psychologists should also be well informed of the impact of basic functions in the management and treatment of depression; that is, the importance of sleep, diet and exercise! Any treatment approach, that is, any jazzy new drug and/or therapy technique will not get anyone very far if a person is not sleeping well, eating well or exercising! The importance of these fundamentals are often overlooked, or expected to improve as a result of an effective drug. This is not the right way to think about things. People have a huge amount of power in managing their depression by tending to their sleeping, eating and lifestyle habits. These factors alone affect everyone’s mood, and in some contribute to depressive tendencies or episodes.

So what I’m saying is, apart from family doctors, psychiatrists, and psychologists, the individual has a huge role to play in their recovery from depression. One theory of depression is “learned helplessness”, which refers to the belief that no matter what one does, it will not have an effect—so they give up. I work with clients to counteract this hopeless and helpless stance, and I insist that they do their part by eating well, trying to maintain good sleep habits, healthy lifestyle habits and in general taking good care of themselves. Many of my clients with severe depression completely neglect their self-care, they don’t eat properly, they don’t shower, they don’t leave the house, etc. I do not accept answers such as, “I will walk more as soon as I feel better.” This is the depression mindset speaking. I explain to my patients that they will be able to rationalize their way out doing anything to help themselves when they are depressed. This is their depression speaking. And it will keep them stuck. So I refer them to the Nike motto “JUST DO IT”. Don’t think about it, don’t “feel” about it, just DO IT. Put on that runner and step outside the door. I don’t care if your heart is not in it, and you are functioning like a robot. Getting outside will oxygenate you, which will have an impact on your thought processes, which may have an impact on how you feel, and if you keep up the daily morning walk, it will have a cumulative impact, and the brain will have developed a new healthy habit.
This is cognitive behaviour therapy by the way, CBT, where we focus on cognitions/thoughts, feelings and behaviours. People think that when they feel better, they will “do” better. Well, we’re in for a long wait if we leave it up to depression. It is just the opposite. Changing their behaviour will lead to feeling better. The point is change your behaviour in order to feel better. Just DO IT! I love to see clients become empowered, to see them turn little successes into big ones and take command over their lives, take command of the oppressive beast called depression.

Please stay tuned for part two of three in this series, appearing in our November edition, where we will discuss treatment options and prognosis for clinical depression