Category Archives: Psychology

Mild Depression, A Mild Problem?

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More from Peter Cramer’s book Against Depression, which I heartily recommend to anyone who wants to learn more about depression.

We talked about the full blown diagnosis of depression. For a diagnosis of major depression you need 5 or more symptoms for at least 2 weeks. What if a patient has only 2 or 3 symptoms for 2 weeks? Is that a problem?

First of all these mild depressions can be the precursor or follow-up to major depression. So they are important for that reason.

But even if there is no major depression, mild depression looks like major depression. Mild depression runs in families where major depression is prevalent. Low level depression causes disability, absenteeism, more medical visits.

Another type of mild depression is dysthymia. Dysthymia means being sad at least 50% of the time, for 2 years or more. And dysthymia is not the same as unhappiness. Dysthymics suffer the same relentless internal stress, the hopelessness, sadness, and low self-esteem of the depressed. The fact that they may function well, or eat and sleep well, is of small comfort to them.

The problem with dysthymia and mild depression is that medications may be less effective with these conditions, and some types of psychotherapy, more effective. Although no one exactly knows, the general consensus is that dysthymia is less responsive to antidepressants than is major depression. But it may be more responsive to cognitive behavioral therapy.

In summary, even mild depression has serious impacts on people. Mild depression can be effectively treated with cognitive behavioral therapy, and responds well to it.


Copyright 2006 The Psychology Lounge/TPL Productions

The Natural History of Depression

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I’m still reading Peter Cramer’s book Against Depression, which is his follow-up to Listening to Prozac, his groundbreaking book about depression and Prozac. This is a fascinating book, as good as Listening to Prozac. I continue to be impressed by his scholarship and ability to pull interesting research together. If you have any interest at all in learning more about depression, I would strongly recommend this book, which is a philosophical and scientific exploration of depression.

What is the natural history of depression? That is, what happens later in life if you get depressed now? Do you recover, or do you have more depressions?

We have good data on this issue from some studies funded by the National Institute of Mental Health. These studies followed depressed patients over many years. The findings are astounding, at least to me.

They show that if you are diagnosed as being depressed today, there is a 20 percent chance you will still be depressed 2 years later, and a 7 percent chance you will still be depressed ten years later, and a 6 percent chance you will be depressed 15 years later!

Even if you recovered, your probability of relapse is high. In these studies, most patients had subsequent depressions: 40 percent at two years, 60 percent at five years, 75 percent at ten years, and 87 percent at 15 years.

And with each episode of depression the prognosis worsens. After the second episode of depression, the 2 year recurrence rate soars to 75 percent!

One likely explanation for this effect is called kindling. The kindling model was first developed to explain how epilepsy works. In epilepsy, each seizure you have makes you more likely to have more seizures. This is because the seizure damages the brain.

We now think that each major depression may alter the brain as well. Particularly it may cause a shrinking of cells in several important areas of the brain. One of these is the hippocampus, which governs the formation of short term memory. Another is the prefrontal cortex, which has many functions in reasoning.

And how many patients got treatment? Only 3 percent of the patients who were diagnosed with depression had ever received even a single one month trial of anti-depressant medication! This is shameful in a country that claims to have good health care.

So what do we learn from these studies?

  1. Depression is a chronic disease, and relapse is very high.
  2. Each relapse makes you more susceptible to future depressions. Each depression erodes the resilience of the brain.
  3. A small but substantial percentage of depressed patients remain depressed for years on end.
  4. Prevention of initial depressions, early treatment of major depression, and prevention of future depressions can change the natural history of depression, and prevent a lifetime of depression.


The other important thing to realize about these studies is that they only looked at major depression. That is, at depression with many serious symptoms. Later studies that have looked at milder versions of depression have found that even mild depressions predict future major depressions. A future post will talk about minor depression, or dysthymia.

Copyright 2006 The Psychology Lounge/TPL Productions

Depression: No Big Problem? Right? Wrong!

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Here is some more good stuff from Peter Cramer’s book Against Depression, which is his follow-up to Listening to Prozac, his groundbreaking book about depression and Prozac. This is a fascinating book, as good as Listening to Prozac. If you have any interest at all in learning more about depression, I would strongly recommend this book, which is a philosophical and scientific exploration of depression. Much of what follows is inspired by this book.

How big a problem is depression compared to other illnesses? Other health problems such as AIDS, arthritis, heart disease, diabetes, and cancer are much bigger problems, right?

Wrong. If you look at the impact of depression on disability, very interesting facts emerge. Let me explain how these figures are calculated. Imagine a 20 year old woman develops chronic depression that causes her to be 1/3 disabled for the next 60 years. That means she loses the equivalent of 20 years of life, which is the same as if a healthy woman died at age 60 instead of the normal lifespan of 80.

When disability from depression is calculated this way, the figures are astounding. The World Health Organization looked at this data from around the world. They found that by the year 2020 depression will be the largest cause of disability with the sole exception of heart disease. Even in 1990, depression was already the number one cause of disability within the major chronic diseases of midlife. Major depression accounted for almost 20 percent of disability-adjusted life years lost for women in the developed countries. This was more than three times the amount caused by the next illness.

Other studies looked at the impact of depression in the workplace. In the United States this cost is estimated at over 40 billion dollars, which is almost 3% of the total economy. Being depressed on the job is estimated as the equivalent of calling in sick half a day per week.

Just how common is depression? There are many studies and they often disagree, but the best studies suggest that about 16 percent of Americans will suffer a major depression over their lifetime. That is almost 1 in 6 Americans. Look around at your friends and family and co-workers, 1 in 6 of them will suffer a major depression. In any given year, between 6-7 percent suffer major depression.

And depression has major health implications. Studies that look at elderly people find that depression increases the risk of death very significantly, independent of suicide. One study found that elderly people who were depressed were 40 percent more likely to die than those who were undepressed. When they analyzed the data to see what the cause was, they found that even when you controlled for all other health behaviors and other factors, depression still accounted for 24 percent increase in deaths. This was the equivalent of high blood pressure, smoking, stroke, or congestive heart failure.

So depression is no big deal? Not unless you consider major disability, huge workplace effects, and shortened life a big deal. In reality, depression is one of the most devastating diseases that human beings suffer.

Copyright 2006 The Psychology Lounge/TPL Productions

Depression in Middle Age and Beyond

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Here is some more fascinating stuff from Peter Cramer’s book Against Depression, which is his follow-up to Listening to Prozac, his groundbreaking book about depression and Prozac. This is a fascinating book, as good or better than Listening to Prozac. I continue to be impressed by his scholarship and ability to pull interesting research together. If you have any interest at all in learning more about depression, I would strongly recommend this book, which is a philosophical and scientific exploration of depression.

What about those people who have their first depression later in life? Are they similar or different to those who get depressed earlier in life?

What is interesting is that there may be a type of depression in older adults that is physically triggered. Let me tell you a story about how this was discovered.

Much of this research was conducted by K. Ranga Ram Krishnan and his group at Duke University. In the 1980’s they got their first MRI machines. These machines let you take detailed pictures of the brain without using radiation (they use magnetic resonance imagery instead.)

His group didn’t really know what to do with these new machines. So they decided to take a look at the brains of elderly depressed patients. What they found was fascinating. In 70% of the patients who had suffered late in life depressions, they found small white patches in various areas of the brain. When they autopsied some of the these patients who later died, they found that these were lesions in the brain that ranged from tiny pinpoint lesions up to rather large (2 inches in diameter) lesions. These were where silent strokes had occurred, killing the brain tissue.

Silent strokes are those strokes that happen in a part of the brain that does not control sensation or motion, so you often are unaware you even had the stroke.

This led to the realization that these people were suffering from vascular depression, that is, depression caused by damage to the brain from a silent stroke.

The main area of the brain where Krishnan found these lesions was the prefrontal cortex, or more specifically the orbitofrontal cortex, right behind the eyes.

These depressions were very similar to regular depression, with the main difference being that this group generally hadn’t suffered depression earlier in life.

The good news is that these depressions respond well to antidepressant medications, and the patients tend to get well just like regular depressions.

In summary, if you or a relative suffers a sudden depression later in life, suspect a vascular depression. And get treatment. (Also, if your elderly relative suffers a vascular depression, they may also show pseudo-dementia, which is a type of cognitive impairment which is caused by serious depression. It can look like they have suddenly developed Alzheimer’s or some other dementing disorder, but it actually is a side effect of the depression. Treating the depression will often resolve the pseudo-dementia. )

Most important, if a doctor or psychologist tells you that your older relative is depressed because they are old and sick, don’t accept this. There is no reason for the elderly to be more depressed, in spite of age or infirmity.

Copyright 2006 The Psychology Lounge/TPL Productions

New Research into the Causes of Depression

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Lately I’ve been reading Peter Cramer’s book Against Depression, which is his follow-up to Listening to Prozac, his groundbreaking book about depression and Prozac. This is a fascinating book, as good as Listening to Prozac. If you have any interest at all in learning more about depression, I would strongly recommend this book, which is a philosophical and scientific exploration of depression. Much of what follows is inspired by this book.

Today I want to talk about the new and exciting research on depression done by Kenneth Kendler at the Virginia Commonwealth University.

Dr. Kendler has looked at the causes of major depression. His research finds that there are three pathways to depression. That means there are a number of different triggers that cause people to become depressed.

The first is what he calls the internal pathway. This includes two variables that predict depression–childhood onset anxiety disorders (before age 18) and neuroticism (a general trait of psychological disorder). This means that if you have an anxiety disorder as a child, or if you are generally neurotic, you are more likely to become depressed later in life.

The second is the external pathway. This path includes two variables: conduct disorder and substance abuse. (Conduct disorder means getting into trouble with the law.) So if you abused alcohol as a teenager, and got arrested, you are more likely to get depressed later in life.

The third path is not surprisingly, through adversity in life. And this pathway is the most complex. It starts in childhood with a disturbed family environment, childhood sexual abuse, and the loss of a parent. It continues with low educational achievement, lifetime trauma, low social support, and the likelihood of divorce. Finally, it ends with current stressors such as marital problems, life difficulties, and stressful events in the last year before depression starts. Kendler believes that much of the adversity that people experience are actually interpersonal difficulties.

What is worse is that the factors are related to one another. If you have adversity in childhood, you are more likely to develop conduct disorder and substance abuse, and these disorders make it more likely you will get into a bad marriage, lose your job, etc.

This complex model was able to account for 52 percent of the likelihood of depression in a one year period.

So far none of this is really that surprising or interesting. After all, most people would predict that a lousy childhood, getting into trouble, and being anxious might lead to depression.

The really interesting part of his research is how these factors influence one another, and how the genetic component influences all of them. Genetic factors influence all three of the major factors. If you are genetically prone to depression, you are more likely to have a lousy childhood, get into trouble and abuse substances, and be anxious and neurotic! How does this work?

Kendler isn’t sure, but suspects that if you are prone to depression, your parents might have been also, and this impaired their ability to parent well. Or perhaps, it is harder to parent an anxious, depressed, neurotic child. Or perhaps both are true; depressed parents have a harder time parenting, and their children tend to be moodier and harder to deal with. The genetic propensity to depression may also be connected to substance abuse directly or as an attempt to self-medicate the depression.

Other findings from his research. He found that if you have an anxiety disorder before age 18, this is a strong and independent predictor of depression.

So what can we learn from this research?

There appears to be a tragic path to depression. The depressed person is born with a genetic tendency to depression which in turn is correlated with the likelihood of a bad childhood. Then they do worse in school, get in trouble more, turn to substance abuse, and then aas adults pick bad relationships, have more conflict in jobs and family, and are more likely to be traumatized. Basically their whole life goes poorly. Chaos and conflict and loss and low social support leads to depression. A single depression leads to future depressions.

It is all pretty depressing! But what it shows is also the pathway to healing. For instance, therapy in childhood may help prevent some of this. Treating early anxiety disorders or substance abuse may prevent some of the later chaos.

It also shows why therapy is so important in the treatment of adult depression. Although anti-depressant medications may help with the biological problems in depression, therapy is necessary to help clients learn new ways to relate to people and how to make better interpersonal decisions. A supportive therapist may also help buffer the effects of adversity and loss and make depression a less likely outcome.

This research also suggests that depression is not just a mood state, but is an illness that affects many aspects of a person’s life (and in a negative direction.) We need to be aggressive in treating this serious and debilitating illness.

Copyright 2006 The Psychology Lounge/TPL Productions