On September 3, 2014 I was faced with the realization that there was something seriously wrong with me. The word “depression” kept being raised by hospital staff but what exactly did they mean? I knew I was suffering, and had suffered for a long time from a Black mood, but it seemed to me to be more than just being depressed. After all, people get depressed when someone dies, or they lose a job, or they break-up with their girlfriend and none of these events were present in my life. Moreover someone who is depressed seems to pull out of it after a reasonable time. But none of that applied to me. There was no identifiable cause and I certainly wasn’t pulling myself out of The Black mood, so how could I be depressed? What was going on with me?
Once released, I Googled “depression” to get a sense of what everyone was trying to tell me. While I saw echoes of what I was experiencing on many of the web sites I looked at, I wasn’t fully convinced, primarily because there seemed to be a number of different conditions commonly labelled “depression”. Which one, if any, applied to me?
The answer was furnished when I was finally interviewed by a psychologist and a psychiatrist who, after the interview, told me I suffered from Major Depressive Disorder (MDD).
I now had a specific condition to research, and research I did. My research directed me to the source definition used by mental health professionals. The American Psychiatric Association (APA) publishes the Diagnostic and Statistical Manual (DSM) which codifies and defines all psychiatric disorders. Additionally, the APA also publishes a number of companion manuals which instruct the professional on how to interpret and apply the definitions found in the DSM.
I was fortunate to be given the opportunity to review a number of different sources. After reading them, and asking questions, I arrived at a layman’s understanding of what Major Depressive Disorder is.
The disorder has five essential elements:
- impairment in functioning over the entire duration,
- a lack of a physiological or general medical cause,
- clear physical affects that are more than mood,
- the presence of five (or more) symptoms throughout the entire duration which must include either depressed mood or loss of interest or pleasure.
Duration is probably the only clear-cut element of the definition. The duration is two weeks. Everything else within the definition must happen within the two weeks.
Everyone has bad days, everyone feels blue from time to time, but not everyone has Major Depressive Disorder. So, the definition tries to discount the possibility that the person is experiencing everyday sadness by calling for a period of time that is long enough that would allow any everyday sadness to pass in the normal course of events. If it does not, then a depressive episode may be present.
Major Depressive Disorder is the second leading cause of disability in the United States (and a leading cause of disability globally). Forty percent or more sufferers of the disorder will consider suicide, with ten percent succeeding in their attempt. This translates to over two million deaths in the United States each year and far more globally.
Even though the defined duration is short, a typical bout of MDD lasts a minimum of six months and can last for years. Please keep this in mind as we explore the definition further.
The definition then presents a list of affects (symptoms), five of which must be present. They are:
- Depressed mood most of the day, nearly every day;
- Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day;
- Significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day;
- Insomnia or hypersomnia nearly every day;
- Psychomotor agitation or retardation nearly every day;
- Fatigue or loss of energy nearly every day;
- Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day;
- Diminished ability to think or concentrate, or indecisiveness, nearly every day;
- Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.
The key is the phrase “nearly every day”. While most sufferers feel like they experience these symptoms on a 24/7 basis, the fact is they will smile or laugh or have energetic days. But these moments do not last – they are fleeting – and they leave no memory because they get suffocated by the feelings of loss – of loss of pleasure, of loss of energy, of loss of the ability to think or do, etc.
These affects must not have another medical cause – that is, be attributable to another condition. For example, restricted mobility due to a broken leg will not fall within psychomotor retardation; reduced concentration or pleasure due to a drug or alcohol addiction also falls outside the scope of MDD. In other words, the definition attempts to exclude all external causes of similar symptoms and it is only when these external causes do not exist that MDD may apply.
Typically, sufferers of MDD move and think more slowly. It’s as if they are both walking and thinking through quicksand. This slowed movement or thinking can be witnessed by third parties (it often is, although it may never be mentioned), including your physician and mental health professional. Such reductions in ability are more than mood. They are physical manifestations of the mood but are not the mood itself. In this circumstance, they would satisfy the fourth of the key elements we first discussed.
Throughout the previous paragraphs, I’ve given you a layman’s guide to the definition of Major Depressive Disorder. Now, for a moment, I ask you to consider this: each week has 168 hours. Each month has 727 hours. Over six months we have 4,365 hours (give or take). Imagine experiencing a loss of joy each of these hours, every hour. Imagine feeling worthless each of these hours, every hour. Imagine both of these together. Many of you cannot do this because it is beyond your frame of reference. That is what makes understanding the disorder so difficult.
In my case, I checked off each and every element of the definition. I experienced all nine affects, had pervasive low mood, lost pleasure in all previously pleasurable activities and suffered for the minimum two weeks (it was, in fact, years). The cumulative nature of experiencing so many affects is exhausting and causes very real physical and mental pain. It is my personal belief that the symptoms act as multipliers of each other, but even just adding one on top of the other is a huge burden.
I remind you that I’m not a mental health professional. I live with Major Depressive Disorder and, from time to time, I experience depressive episodes. The most recent depressive episode prompted my reaching out for help. My own research, the guidance and lessons shared by fellow-sufferers, the compassion of therapists, and so much more, have all inspired me to share what I’ve learned with you. It’s information. It’s not a diagnosis. If you believe that you’re in need of help, I urge you to speak to your family doctor. If you are experiencing suicidal thoughts, SEEK HELP IMMEDIATELY BY DIALING 911 OR VISITING YOUR LOCAL HOSPITAL EMERGENCY ROOM.
I hoped to give you a sense of that sufferers may mean when they use the word “depression”. It is much more than sadness, or low mood. It is a serious and deadly illness worthy of your respect and the sufferer is worthy of your kindness and compassion.
By the way, the word “depression” never appears in the definition of Major Depressive Disorder. That’s why I prefer to talk of depressive episodes.