© Peter Smith –Holistic Medicine Practitioner- (updated 1/Feb/2013)
There are many different types of depression:
from major depression to dysthymia,
from postpartum depression to seasonal affective disorder.
Also called clinical depression, it might look something like this: there may be a very intense debilitating initial phase of relatively short duration lasting from several days to several weeks (although in severe cases it can last much longer), after that the symptoms may become less severe and no longer debilitating although still incredibly painful and unacceptable, this recovery phase is likely to last from several months to a year or two as the symptoms gradually improve and the person returns fully to normal.
It's possible for a person to have a single episode like this once in their life and that's it, or it may recur a few times throughout the person's life. For a few unfortunate individuals bouts of major depression recur repeatedly many times throughout their life.
Dysthymic depression or dysthymia is continuous daily depression which lasts several years, it may not be as intense as major depression but it is still a serious illness, perhaps even more destructive to a person's life than major depression. Imagine a bout of major depression was an initial 2 week intensive phase then followed by a six-month recovery period, in terms of time off work and debility you could liken this to a bad dose of the flu. It could be argued that one episode like this every 10 years would disrupt a person's life less than spending 8-10 of those 10 years suffering from daily this dysthymic depression. To be classified as dysthymia it must last at least 2 years.
Dysthymia and major depressions can combine where a person has bouts of clinical depression and never really fully returns to normal between bouts of major depressions. This is called double depression.
I recommend people with such severe and continuous depression seriously consider the possibility that they in fact have bipolar syndrome or bipolar syndrome type II which can go undiagnosed for years especially if the manic symptoms are not extreme. Discuss in fine detail the symptoms of bipolar syndrome with a mental health professional to see if you have hidden unrecognised bipolar syndrome. See about bipolar syndrome
Depression can be characterised by a state of heightened emotional sensitivity with extremely intense painful feelings, think of the archetype of the tortured Russian poet, I believe a lack of serotonin is involved in this type of depression. Alternatively depression can be a low energy condition, the person loses their motivation, interest and enthusiasm; distinctly different to the antsy painful serotonin deficient depression above, I believe a lack dopamine is involved at the root of this type of low energy depression.
With the painful serotonin deficient depression thoughts of suicide would be to end the pain, with dopamine deficient depression interest in suicide would be because life loses meaning and pleasure so what's the point to life carrying going on.
There’s a type of bipolar syndrome called bipolar Type II in which there can be long period of depression and the manic episodes are not particularly extreme or obvious, compared to bipolar type one in which the manic episodes are so extreme and hyper that it is obvious the person is hyper-manic. Consequently bipolar type II is often misdiagnosed as endogenous depression. Unfortunately without a proper diagnosis and treatment this illness can seriously harm a person's life. If you have had long term endogenous depression carefully consider the possibility that you have bipolar Type II, do you manifest any hypo-manic phases? See bipolar page
The important difference is in endogenous depression treatment is focused pulley on increasing deficient neurotransmitters, usually serotonin but also sometimes dopamine. Bipolar on the other hand is dominated by imbalances in dopamine activity, not only too little but sometimes too much.
Living with & Treating Depression
[UNDER CONSTRUCTION] depression can be short, long. occasional one off [LINK to treatment ]
How does Depression Manifest?
The terms reactive depression and endogenous depression have become a bit old fashioned however I think they are still useful terms to help us understand depressive illness.
Reactive depression is when the depression is a response to bad external events or experiences that overwhelm your mental capacity to cope.
Imagine an otherwise healthy person becomes depressed as a consequence something bad and painful happening in their life. The classic example would be depression following the death or loss of a loved one. Experiencing grief and bereavement following the loss of a loved one is of course a normal –and one could argue a healthy- response. It should only be considered a medical problem and classified as reactive depression if its severity is causing significant harm to a person’s ability to function over an excessively prolonged period of time. What constitutes excessively prolonged is of course a value judgement, but value judgements are a standard part of diagnosing depression.
Reactive depression is more than just unhappiness or being stressed. Let's return to the example of grief and bereavement: following the loss of a loved one day person will doubtless feel very sad, unhappy and maybe distraught which are normal responses and not mental illness. However when someone becomes so overwhelmed by these feelings that they cannot cope with their work or private life or become at risk of suicide they can be considered to have reactive depression. Imagine our capacity to cope with stressful situations is like an elastic band and can only be stretched so far before it catastrophically snaps and the person has what used to be called a nervous breakdown. When you see or experience this first-hand it’s quite obvious that something very different off the normal range of stress has occurred and the person has gone beyond their ability to cope and takes on all the qualities of a major depression. This condition will typically only last a few weeks, months but occasionally it can last for years. Whether is a risk of serious harm such as suicide a combination of very regular psychotherapy (more than once a week even) and "aggressive" antidepressants treatment is recommended.
It would be irresponsible of me to suggest anybody at risk of suicide from depression not to take antidepressants; however you should be informed that it takes at least 2-4 weeks before antidepressant drugs begin to help and their initial effects are often to increase the risk of suicide, so it is incredibly important to quickly set up adequate support both personal and professional during the initial major depressive phase of a reactive depression. The two quickest acting antidepressant treatments are bright light therapy using what is called a SAD lightbox and a natural remedy SAM-e. Bright light therapy has historically only being considered as a useful antidepressant therapy in cases of what is called winter blues a type of seasonal affective disorder, however there is solid scientific evidence that it is a mild but effective antidepressant as reliable as pharmaceuticals but notably quick acting see the free online e-book Bright Your Life by Krypke.
As well as the above short-term reactive depressive episode it is possible for someone to fail to recover from a significant emotional event in what might be considered to be a reasonable period of time. For example I have met people who were absolutely stuck and unable to move on from the loss of a loved one or the breakup of a relationship after 20 years. It's not that there’s some set time limit for a person to recover or come to terms with a significant emotional event, if they continue to feel sad for five years after something that most other people would recover from in two years it's simply the best they could do with the inner resources they possess; just because someone is taking a long time recovering does not mean they need therapy or antidepressants. As long as they are still processing, moving forward and continuing to integrate the pain of the event they should not be considered mentally ill with reactive depression. Sometimes however it is apparent that the mental healing processes have become stuck. It's like a wound that won't heal.
Current scientific thinking is that what causes a normally healthy individual to develop reactive depression following a significant emotional event is an underlying deficiency in neurotransmitters, despite this I would still recommend using psychological approaches rather than chemical.
Endogenous depression appears to come out of nowhere and without justifiable explanation for no apparent external reason.
What Causes Endogenous Depression?
If you search online you'll see two entrenched positions on this question. One side argues that depression comes principally chemical and physiological imbalances in the brain, some of the evidence for this comes from independent academic research into how the brain works but the majority of the evidence for the biochemical basis of depression comes from research funded by the pharmaceutical industry which only puts its money into potentially profitable endeavours. This builds up huge bodies of evidence only in narrow areas, for example as soon as it’s found raising serotonin has an antidepressant effect and profitable drugs can be produced to do this tones of research funds are poured into serotonin deficiency being the only cause of depression. In chasing after serotonin solutions the role of other neurotransmitters such as dopamine phenylethylamine get left behind. In my book on balancing brain can depression and bipolar syndrome due out 2013/14 I give each of the important neurotransmitter is a separate chapter and discuss the characteristics of that neurotransmitter to assist you to recognise when a deficiency of a particular neurotransmitter is causing your depression and then non-drug therapies to boost it.
I have no doubt that raising serotonin can have an antidepressant effect at least in some people, in addition to the research I have professional and personal experience that it does. Antidepressants however not the only way to raise serotonin there is evidence that raising the level of tryptophan (the amino acid that serotonin is made from) in the brain increases the production of serotonin, three doses per week of this simple low-cost solution effectively protect me from serotonin deficient depression. Other effective ways to raise serotonin include bright light therapy and some herbs. Unfortunately these low-cost therapies are unpatentable so they do not attract enough research and medical promotion funds. Techniques become developed in medicine not just because useful or affective but because they're effective and profitable. I'll leave this now as this website is not concerned with the economic and politics of medicine is concerned with effective non-drug solutions for mental health problems wherever they come from.
Before we presume endogenous must be caused by a chemical imbalance, I would like to propose a new term: delayed reactive depression. Like the more obvious reactive depression the cause of delayed reactive depression is an emotional reaction to significant unpleasant experiences in the outside world, but in this case the negative experiences occurred not in the present but in the past and a person may think that they’ve gotten over them, they may not even have very strong conscience memories of the original experiences but the experience is programmed into the subconscious beliefs and feelings that now come to the surface.
The alternative view you’ll find is that depression has nothing to do with brain chemistry, that psychological forces the course. Again there is evidence that least for CBT and psychodynamic therapies that they can be as affective or sometimes more effective than the pharmaceuticals. I've seen with my own eyes people recover from depressive ways of thinking by changing their psychology with psychotherapy and fully endorse it, and psychotherapy perhaps reduce the severity of my bipolar syndrome by perhaps half it hard to say but it helped a lot. However if I use myself as an example despite spending 15 years refusing to accept I have a neurotransmitter imbalance and that I could cure my condition with enough psychotherapy to change my psychology, I gradually had to concede that although psychotherapy reduced the severity of my condition and help me to manage it I would still occasionally (about a couple of times a year) have to fight off depressive episodes and rapid bipolar cycling with chemical remedies, and that when a depression would get a hold of me it was the chemistry not the psychology that would really treat the condition.
I notice how some of the most outspoken psychotherapists who are adamant depression is all in the mind and not in the brain have not had to live with endogenous depression or bipolar syndrome themselves. And I ask them to consider the following why do we therapists have a strict rule of not conducting a therapy session if the client turns up under the influence of drugs and alcohol? Could you hypnotise a drunk person to become sober? Drugs alter the chemistry of the brain, cocaine for example floods the synapses (junctions between nerves cells) with the stimulating neurotransmitter dopamine creating a temporary pleasurable self-confident high, we might want to improve the natural self-confidence and change the low self-esteem or some such in a client that habitually uses to cocaine; but wouldn't conduct the therapy session while they were under the influence. Our psychological programming, memories and experiences may write the script but the neurophysiology and biochemistry of the brain sets the stage and playhouse it acted within. Could you use psychotherapy or hypnotherapy to remove autism or down syndrome and so far I've not met a psychotherapist who will work with schizophrenia and many therapists will take on clients with bipolar syndrome.
I suggest you can simply let go of the arguments claiming depression is all in the mind or all in the brain by asking the question will this technique help me rather than what's the cause of depression. Both balancing neurotransmitters and psychological therapies can work and you can test and experiment with them to find solutions. The advantages to using natural therapies to balance brain chemistry is that they are very flexible enabling you to tailor make your prescription, fast acting and side-effect free.
See Treating Depression and bipolar for more on the mind verses the brain in treatment.
In the practice the difference between reactive depression and endogenous depression can be very blurred and muddled, however the terms are useful as a starting point to understand types of depression and treatment options. What I think is useful out of this simple distinction is anyone who's depression has obvious outside triggers should probably choose to put the majority if not all of their efforts to recover into psychotherapies rather than chemical therapies. Actually I would argue that everyone with depression should have psychotherapy, whatever the type. It’s possible in depression that appears to be an endogenous chemical imbalances that negative psychological programming buried in the subconscious is actually primarily to blame.
You’ll see tests available online claiming to be able to measure the level of your neurotransmitters from a urine sample they’re not even remotely accurate, nor can you determine neurotransmitter levels through blood. At this point in time we do not have any way of determining whether a bout of depression comes from external events, unhealthy thinking processes or chemical imbalances. Anyone who's depression has obvious outside triggers should probably choose to put the majority if not all of their efforts to recover into psychotherapies rather than chemical therapies. Actually I would suggest that everyone with depression should have psychotherapy, whatever the cause.
Even when chemical imbalances in the brain are the primary cause of a person's depression psychotherapy can still be immensely helpful to remodel any negative psychology which may in some way fuel or be fuelled by the primary chemical imbalance. Improving the health of one's psychology is a useful additional tool for the long-term management of depression caused by underlying physiological imbalances in the brain
Understanding Endogenous Depression
Almost invariably when you tell someone you suffer from depression (which may not be a good thing to do) they may say “oh no what about” to which the answer is “nothing in particular, or I don't know”, this can be very difficult for people to understand or relate to. I've tried explaining it to people as a chemical imbalance, in the same way that a diabetic doesn't make enough insulin a person with endogenous depression may not make enough serotonin or dopamine and this affects how you think and feel, but it has been my observation that even after this (I think) pretty clear and simple explanation people still can't understand endogenous depression. I guess it's such a normal human experience to have one's mood and feelings respond to external influences, that it's hard for many people to imagine descending into an intensely painful place for no apparent reason and no longer being able to respond to good or happy experiences in the outside world. When you don't have depression but you feel down in the dumps about something if your friends take you out for a good chat or you take a walk in beautiful countryside it can really help you gain perspective on your problems and pick you up, but this won't help at all when you have actual depression.
People with schizophrenia have given me detailed descriptions of what they experience but I still can't relate to it, I just have try to accept it is the way they say it is. Likewise when people try to relate to endogenous depression because they have experienced some of the listed symptoms like low mood feelings of hopelessness; I suggest that it's a mistake for people who don't have clinical depression even to try to relate it back to their own personal experience. I used to think I could understand what a hurricane was like because I have experienced hard driving rain, powerful winds, hailstones, lightening etc but then somebody told me about their experience on a small tropical island as a hurricane moved over the top of them. There was only one concrete structure on the entire island and for three days all the island inhabitants and tourists took shelter in the underground opened door to car park, the noise was so loud you couldn't hear yourself scream, all the windows blew in, the air was full of swirling spray and debris that made it dangerous to open your eyes, even pieces of paper and leaves moved so fast they could cut you and the sea rose up and took some people that didn't make it to the shelter; the maelstrom continued like this for three days and nights, she thought she'd go insane. Then it passed as quickly as it had come and everything was calm. The analogy I’m making is if you’ve not had a major depression you really cannot imagine how bad it is.
Surprisingly despite having had numerous bouts of major depression myself when I am not in a bout of depression I cannot fully understand how or why it is as severe as it is and as soon as it ends I cannot understand what was just going on all the time that had such a powerful hold over me. Whenever a bout of depression would start I would always be surprised by just how severe the experience actually is. I've talked to other people with recurrent (relapsing remitting) depression and bipolar syndrome and they agreed that when the depression returns it can be surprising to them how bad it is.
On the outside a person with depression may appear numb and unresponsive, however on the inside they feels anything but numb. With depression ones inner world is very intense, there can be an overwhelming amount of stuff going on, and all of it painful. The intensity of the inner pain and unhappiness can be so all-consuming it takes up their entire focus, this may make them become unresponsive to the outside world, but it is most decidedly not a numb or un-feeling state. Quite the opposite in fact without adequate serotonin to inhibit unhappy thoughts there is an overabundance of painful feelings; with a lack of dopamine on the other hand one loses all enthusiasm, motivation and capacity for joy, creating a pointless insipid existence devoid of interest and engagement in life.
Today I primarily use nutritional medicine, cognitive hypnotherapy, NLP and Bicom therapy to treat metal, digestive and functional health problems like chronic fatigue and IBS.
I have extensive experience (both professional and personal) and a forthcoming book (2013) in nutritional approaches to balancing brain chemistry and psychological approaches to treating depression, bipolar syndrome and anxiety.
I practice at the Hale Clinic (central London) as a holistic medical practitioner and have been in practice since 1988.
Over the years I’ve trained in Nutritional /naturopathic medicine, body-cantered psychotherapy, Chinese herbal medicine, Acupuncture, Bicom resonance therapy (which treats allergies and viruses), meditation, Kundalini yoga, Cognitive Hypnotherapy and NLP.
For a more information on my practice and a list of conditions I treat click here About My Practice
For bookings call the Hale Clinic reception
020 7631 0156
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© Peter Smith –Holistic Medicine Consultant-
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