About two years ago a patient of mine, Mr. Burndt, committed suicide. When his wife, who was also my patient, told me the news at one of her visits, I was shocked. Fully aware that 40% of older patients who are suicidal visit their primary care doctors within one week of killing themselves, I found myself wondering over and over how I'd missed recognizing the severity of his distress. I'd known he'd been suffering from depression but had thought it mild.
But even more shocking than the news of his suicide was the reason his wife gave for it: six months earlier, he'd been involved in a car accident and had inadvertently killed a pedestrian. In the end, he simply couldn't live with the guilt.
WHAT IS DEPRESSION?
The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) classifies depression into the following types (there are even more, but these cover the basics):
- Dysthymia. In essence, having a depressed mood on most days for at least two years.
- Major Depressive Disorder. In addition to feeling "down" as in dysthymia, other characteristics may include excessive feelings of guilt and suicidal ideation, as well as various physical symptoms like loss of hunger and fatigue. It can be mild, moderate, or severe.
- Adjustment Disorder with Depressed Mood. This is grief due to a loss of some kind (which itself can be classified as normal or complicated).
- Depression NOS (not otherwise specified). Includes things like premenstrual depression and seasonal depression (SAD).
- Secondary depression. Depression due to an underlying medical disorder like Cushing's disease or hypothyroidism.
Though not in DSM-IV, some practitioners further classify depression into two broad types:
- Endogenous (or chemical) depression to denote depression that arises without an obvious identifiable cause, thought to reflect some kind of "chemical imbalance" in the brain.
- Exogenous (or external) depression which is thought to arise from a specific, identifiable external cause.
Given this confusing and non-parallel classification scheme it's astonishing doctors don't become depressed themselves as they try to figure out into which bucket their patient's depression fits!
How can we make sense of all this and, more importantly, understand the real cause of depression in order to augment the effectiveness of currently available therapies?
MIND VS. BRAIN
First, we need to recognize the distinction between chemical and external depression has become outdated. Many neuroscientists have suggested that the mind arises from, and is actually caused by, the physical brain, meaning chemical and electrical reactions somehow give rise to thoughts and emotions. Evidence in support of this theory can be found in numerous studies that show altering brain chemistry with anti-depressant drugs (chemicals) can make depressed people feel better emotionally. The same is true for anxiolytics (like Valium) and their effect on anxiety.
But recently, with the advent of functional MRI scans (fMRI), we now have proof the opposite is equally true, that changes in thinking cause significant, measurable changes in brain chemistry and functioning. In one study, patients suffering from spider phobia underwent fMRI scanning before and after receiving cognitive behavioral therapy aimed at eliminating their fear of spiders. Scans were then compared to normal subjects without spider phobia. Results showed that brain function in patients with spider phobia before receiving cognitive behavioral therapy were abnormal compared to subjects without spider phobia but then changed to match normal brain patterns after cognitive behavioral therapy. This may represent the best evidence to date that changes made at the mind level are able to functionally "rewire" the brain, and that the brain and the mind are more mutually influential than we'd previously thought. It certainly supports the Buddhist view that brain and mind are in fact only two sides of the same coin, or different ways of viewing the same single thing.
DEPRESSION ALWAYS HAS A CAUSE
Where, then, does the true cause of depression lie? I would argue that depression arises at its core from a belief that we're powerless to solve our problems.
This is clearly true with people who know why they're depressed: invariably, once they figure out how to solve their particular problem, their depression lifts. But I would also argue this holds true for people who are depressed for no reason they know. Why? Because thoughts can trigger feelings that remain stirred up long after the thoughts themselves have been forgotten. Some studies have suggested people think upwards of 12,000 thoughts per day. How could we ever remember them all? Yet a fleeting thought we might have had this morning about the possibility of losing our job can and often does leave an emotional residue that lasts hours, days, weeks, or even longer. I would argue, therefore, any depression that appears to be "chemical" is more likely caused by a thought that simply isn't remembered--a thought about a problem we don't believe we can solve.
Further, sometimes what appears to be a "chemical" depression is caused by a thought that isn't directly or consciously recognized. These thoughts are often about problems that seem so unbearably awful and unsolvable we literally don't want (and often refuse) to think about them (such as our becoming jobless or the prospect of our own death).
Finally, I believe the commonly accepted idea that some forms of depression like depression NOS and secondary depression (#4 and #5 above) are caused by chemical or hormonal abnormalities overstates the case. I'd suggest an alternative explanation, that these forms of depression have a chemical or hormonal influence--reducing our ability to believe we can solve our problems but not entirely eliminating it. At first glance this might not appear to be a significant distinction given how incredibly difficult it is to believe in our ability to solve problems, for example, when experiencing premenstrual syndrome. But knowing intellectually we can win even if we're having a hard time believing it can help to sustain the most valuable thing depression tends to reduce: hope.
HOW CAN WE HELP OURSELVES?
None of this is by any means to say we can simply decide to believe we can solve a particular problem when no solution is obvious or forthcoming. Changing any belief, whether consciously recognized or not, is literally one of the hardest things to do. But armed with a clearer understanding of the true cause of depression we can consider the following steps to help ourselves:
- Find a way to raise your life-condition. Your inner life state has more to do with your ability to believe you can solve your problems than anything that may be actually going on in your life. If your thoughts are swirling in despair, take action to break free of them and attain a fresh perspective. Become immersed in a great book that moves you or watch a movie that transports you. Exercise. Go where it's warm. Chant nam-myoho-renge-kyo. In short, do what you know from experience bounces your thinking to a more optimistic place.
- Identify the problem or problems you don't think you can solve. It's amazing how often you don't know why you're depressed and how helpful it can be to figure it out. Making a list of everything that's bothering you--a sort of stream-of-consciousness rant on paper--can be a fantastically helpful exercise. Or if you do know why you're depressed, recognizing the cause isn't that you have a problem per se but rather that you have a problem you don't believe you can solve can be remarkably empowering. Also, sometimes we become depressed not because we have one problem we believe we can't solve but because we have multiple problems we believe we can't solve. Handling challenges can be likened to balancing a "plate" of a certain size: if we pile too many problems onto it, not only do we risk having it topple over, we often find ourselves wanting to pitch the whole thing on purpose. When this is the case, allow yourself to only worry about and focus on solving one problem at a time.
- Identify the reason a problem seems unsolvable. As I pointed out in a previous post, Changing Poison Into Medicine, many things erroneously cause us to conclude we're deadlocked, chief among them our inability to identify a solution to our problem right now.
- Recognize that your thoughts are profoundly influenced by your mood. Once depression has established itself, it takes on an insidious life of it's own, further diminishing your belief in your ability to solve problems, your ability to plan, and your ability to have hope for the future. In this way the cause of any depression always reinforces itself.
- Remember that your depressed self is not your true self. Whatever life-condition you find yourself in at any one moment always feels like the only life-condition you've ever had or will have. But your life-condition can and often does change literally from moment to moment.
- Understand that anti-depressants only treat the symptoms of depression. None of the foregoing has been intended as a denial that anti-depressant medication plays a critical role in the treatment of depression. In the right patient, anti-depressants reduce the symptoms of suffering exceptionally well and can be literally life-saving. But they can't make anyone actually happy because happiness isn't merely the absence of suffering. The best approach, in my view, is to treat the symptoms of depression with anti-depressants (or cognitive therapy or even electroconvulsive therapy) at the same time you address the underlying cause of the depression itself.
I fully recognize that as a means to battle depression - especially a deep, all-consuming depression - these suggestions are inadequate. My point in making them, however, is to emphasize that the single most effective means to resolve a depression is to find a way to tap into our immense power to solve problems.
In a sense, we're all on a journey to find just such a way. For me, the practice of Buddhism has been a consistently effective means by which to win over obstacles I didn't believe I could, a tool that has enabled me to manifest wisdom, courage, and most importantly concrete solutions I don't believe I would have stumbled upon had I not been practicing. If you have a different means that your experience has demonstrated works, stick with it. If not, spur yourself on to explore other paths until you find one that proves it has real power.
In retrospect, I wish I'd suggested to Mr. Burdnt that he think about his guilt over the death of the pedestrian he caused as a problem to be solved - and more importantly as a problem that could be solved. Perhaps had I also begun him on an anti-depressant medication to stave off what were obviously strong suicidal thoughts, he might have had time to work through his guilt. Perhaps he could have shaken loose from its grip in time to forgive himself, and his depression might have lifted. But I'll never know. And that's a problem I have to solve for myself.