According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), the criteria for Major Depressive Disorder is as follow:
The individual must be experiencing five or more symptoms during the same 2-week period and at least one of the symptoms should be either (1) depressed mood or (2) loss of interest or pleasure.
1. Depressed mood most of the day, nearly every day.
2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day.
3. Significant weight loss when not dieting or weight gain, or decrease or increase in appetite nearly every day.
4. Insomnia or hypersomnia nearly every day.
5. A slowing down of thought and a reduction of physical movement (observable by others, not merely subjective feelings of restlessness or being slowed down).
6. Fatigue or loss of energy nearly every day.
7. Feelings of worthlessness or excessive or inappropriate guilt nearly every day.
8. Diminished ability to think or concentrate, or indecisiveness, nearly everyday.
9. Recurrent thoughts of death, recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.
In today's world, more and more people are suffering from depression. It is sometimes still a taboo to discuss mental illness but it is something that we should not look away from. According to the World Health Organization, depression is a common mental disorder affecting more than 264 million people worldwide. It is also one of the largest burdens in the world today.
This is not difficult to understand, as people that suffer from depression lose interest in daily activities and are unable to hold a job. People who are experiencing depression may find it more difficult during the Movement Control Order. A recent survey showed that Malaysians are reporting high levels of negative emotions during the Movement Control Order. 48% and 45% of respondents self-reported experiencing varying levels of anxiety and depression. This is a worrying trend as people are suffering from mental health deterioration due to COVID-19.
Therefore,to help ourselves and the people around us, we need to have a better understanding of how depression works and how to lift it. There are two concepts crucial to the onset and maintenance of depression which is:
1) Learned Helplessness
The concept of learned helplessness is a concept coined by J. Bruce Overmier and Martin Seligman. The phenomenon of learned helplessness was first described after experiments in which dogs exposed to a series of unavoidable electric shocks later failed to learn to escape these shocks when tested in a different apparatus, whereas dogs exposed to shocks that could be terminated by a response did not show interference with escape learning in another apparatus.
According to the American Psychological Association, learned helplessness occurs when someone repeatedly faces uncontrollable, stressful situations, then does not exercise control when it becomes available. It means we learnt that we do not have control and eventually give up trying, even when change is possible.
To illustrate the phenomenon allow me to share a metaphor. A baby elephant that was trained in a circus learnt to fear his trainer since it was young. Whenever the elephant goes against the trainer, it gets beaten. Over the years, the elephant grew up and is much stronger than the trainer, but yet still fears the trainer.
Another metaphor would be, horses raise in a farm built with electrical fences learnt that every time they touch the fence, they feel pain. In an unforeseen circumstance such as a short circuit, the electric fences stopped working. However, the horses not knowing about the faulty electric fences will still fear to go near the fences. In both cases, the animal learnt that they are helpless against its circumstances and chooses to give up trying and take the abuses.
How does learned helplessness apply to people experiencing depression?
People suffering from depression feel trapped and hopeless. They want to stay at home and avoid activities because they do not feel any pleasure from any form of activity. Any inquiry about why they do not want to go out or exercise, they will tell you they cannot do it due to their depression. What they are feeling is very real and true to them, in the same way, the horses fear electrical fences, the elephants fear their trainer, the person with depression fears and avoids life. It will take time to realize what they fear may no longer be there or may just be temporary.
For example, a person who failed to close a sale may start to fear to make a sale. They might think to themselves, “I am a failure and I can never close a sale”. When he starts to dwell in these thoughts, he feels more depress, not understanding that one failure does not equate to multiple failures. However, he may fear doing sales again, because he fears failure and rejection, not understanding it may only be temporary if he improves his communication skills. However, to get this insight, people usually need to engage in therapy. The process can be guided by a professional, and in that process, the person can relearn how to help themselves.
Therefore, to see the illusion of being trapped or feeling helpless, to break free from the vicious cycle of failure and depression, to unstuck yourself and to lift yourself out of your depressive mood, therapy can be beneficial for the above purposes. This is because people’s perspective changes when they engage in a dialogue. Sometimes, an idea like learned helplessness is hard to grasp just by reading an article or reading a book.
Research / References
One of the biggest myths that people believe is that if you have depression, you should rest at home to get better. Most people do not understand depression works differently from other types of diseases such as the flu or the fever. If you catch the flu or fever, taking an off day, resting at home until you feel better will work. However, if you use the same strategies to treat depression, it will likely backfire. What’s the reason behind that? Therefore, you need to understand the concept of rumination to understand why these strategies will backfire.
To understand rumination, we need to understand the meaning of the root word, “ruminant”. The word ruminant is used to describe the process of chewing food over and over again by plant-based mammals such as cows and goats. The definition of rumination comes from the word “ruminant” and is used to describe the act of repetitive thinking of negative thoughts as if chewing or dwelling on the thoughts over and over again. There is robust evidence showing rumination in the onset and maintenance of depression (Nolen-Hoeksema et al., 2008; Watkins,2008). Therefore, given this understanding, we learnt that if someone does nothing, takes a day off and rest, it will likely result in more rumination.The more you rest, the more free time you have will have, and you will likely use that time to dwell on negative thoughts.
How does rumination look like?
For example, when you are stressed at work, you may under perform and get a scolding from your superiors. You may then start to think to yourself, “Why am I so bad at my work?”. Following that thought, you may start thinking, “Why am I useless?”. When you start thinking about those thoughts repeatedly, you then start to feel bad about yourself, and you start to feel like you do not want to work. You may want to take a day off from work to help cope with the stress. However, not understanding how rumination works, you may find yourself even more stuck. During your day off, you will then start to ruminate about what happened previously at work. You will then find how mentally drain thinking about work on your off day. Your mood may start to shift and you will likely feel depressed. Following these thoughts, you will start to think to yourself, “Why am I depressed?”, “Why am I unproductive?”, “Why can’t I go to work?”. All these thoughts will lead to more fatigue and agitation leading you into a vicious cycle of unproductive thinking. You may feel less and less motivated to go to work. Some people at this point will turn to alcohol or substance use to make themselves feel better.
Rumination then exacerbates the feelings of learned helplessness. Thus, making a person feel trapped deeper in the vicious cycle of depression. If we look at rumination, it is a form of mental habit. Rumination is the process of trying to make sense of things that we do not understand. It usually happens when the goals we set for ourselves do not meet our expectations. In that process of making sense of unresolved goals, we dwell in our thoughts. The mental energy we used up in rumination is usually not fruitful, we blame ourselves more and feel more tired after rumination. When that happens, we ruminate about our failures. When we are stuck in the cycle of ruminations, it will start to affect our daily routines and sleep cycles.
Rumination and Sleep
People who engage in rumination feel more tired, lethargic and have disrupted sleep cycles. Rumination is a learned habit that is mentally draining and emotionally charging. Every time you ruminate about a negative event, it creates negative emotions. Some people describe depression as a heavy burden or a heavyweight on the mind, some people describe depression as a black hole that sucks out all your energy. These descriptions are anecdotally accurate because when you ruminate, you charge up negative emotions in you, which feels like creating a heavier weight on your mind, leaving you with fatigue. Your mind and body wanting to protect itself will send out signals for you to sleep and rest.
However, if you sleep too much during the day, it will start to disrupt your sleep cycle. When you disrupt your sleep cycle, you will start to experience insomnia or hypersomnia. Therefore, the next symptom will be sleeping and waking up at odd times. When you start to experience that, you may even begin ruminating about your sleep which makes things worse. You may start to think about, “Why can’t I sleep?”, “Am I going crazy?”, “I am so useless”. Then, round and round you go into a vicious cycle of maintaining your depression.
Therefore, when we understand how depression is maintained, we can target these processes to lift the depressive mood. There are specific techniques to reduce rumination, and by doing that, we can break free from the vicious cycle of depression. In part 3 ,we will write about, treatment for depression which includes pharmacological treatment and psychological treatment. Treatment helps people to be able to manage their lives again and to help people help themselves. When you can learn these techniques in therapy you may find that you are not powerless against rumination or depression.
1) Nolen-Hoeksema,S., Wisco, B. E., & Lyubomirsky, S. (2008). Rethinking rumination. Perspectiveson Psychological Science, 3(5), 400–424.
2) Watkins,E. R. (2008). Constructive and unconstructive repetitive thought. PsychologicalBulletin, 134(2), 163–206.
Treatment for Depression
Treatment is available for depression. Google search on treatment for depression returns with a result of 579,000,000 links. There are many choices for depression, how does one choose? Generally, treatment for depression consists of pharmacological interventions and psychological interventions or both.
Antidepressants are available as pharmacological treatments for depression. Not everyone is ready and open to psychological interventions. Some people with depression do not want to talk to a psychologist, because it will sometimes make you feel vulnerable. Besides that, people associate therapy with being weak and feeling ashamed of themselves. This is untrue but it’s due to the stigma of mental illness. It makes it hard for people to seek help. You may feel like you want to runaway from your feeling and do not want to talk about those difficult feelings. Yet, you are suffering and know that you need help. Therefore, trying an antidepressant may sound like something you can tolerate. If you are looking for pharmacological help, you can see a psychiatrist and get prescribed on antidepressants.
The selection of antidepressants depends on case to case basis. Generally, a psychiatrist will prescribe a selective serotonin reuptake inhibitors (SSRIs) as a first-line treatment. Depending on your response to the medication and exhibition of side effects, the psychiatrist will adjust the dosage and medication accordingly. Usually, you will be able to notice a difference in 4-6 weeks. A selective serotonin reuptake inhibitors can increase your serotonin level in your brain. Serotonin is associated with a feeling of well being and happiness. When the reuptake of serotonin is inhibited, the level of serotonin in your brain will be increased. Some people start to feel better after taking antidepressants. When they feel better, they start to do more pleasurable activities. Those pleasurable activities will increase their serotonin level in their brain resulting in a reduction of depressive symptoms. However, sometimes pharmacological interventions are not enough. Therefore, some people will need psychological treatment.
Some people are resistant towards medication and they suffer from lots of side effects from antidepressants and therefore make it counter-intuitive to take medication. These people prefer using psychotherapy to treat their depression. There are many types of effective psychotherapy. These include Cognitive Behavioral Therapy, Acceptance Commitment Therapy, Mindfulness-Based Therapy, and so on.
What is important in the early stages of psychological treatment for depression is to target the process of rumination. This means to help you reduce your rumination using psychological principles. Different schools of therapy may use different types of intervention to target the process of rumination. Generally, it will be helpful to do a functional analysis of your process of rumination.
The moment you analyze your process of rumination, you may be able to reduce it. You may notice in some situations, you will ruminate more, and in other situations, you will ruminate less. To do a functional analysis, you will need to monitor the process of your rumination. Before doing a functional analysis, it will be helpful to understand some basic concepts of Antecedent (A), Behaviors (B), and Consequences (C). An antecedent is what usually triggers the behavior of rumination, a behavior will be what happens during the process of rumination, a consequence is what happens after the behavior or what are the after-effects of the rumination. It is easier to explain using an example:
Lying on my bed, feeling too lazy to wake up.
Think about all my past failures and blaming myself for wasting time on my bed.
Feelings of depression and fatigue due to the rumination.
Based on the simple examples above, your therapist will have enough information to target the process of rumination. One of the easiest ways to change a habit is to manage the antecedent. Based on the example above, we know that lying on the bed will trigger an unhelpful behavior of rumination, the prolonged rumination, in turn, will cause the person feeling more depressed and fatigue. To change that habit, we can change the antecedent. Interventions as simple as using an alarm clock, asking someone to help you with a morning call will reduce the frequency of rumination effectively resulting in less depress feelings and fatigue.
Besides targeting the habit of rumination, your therapist may also guide you on behavioral activation in Cognitive Behavioral Therapy. Behavioral Activation is one of the most effective interventions to treat depression. In behavioral activation, you and your therapist discuss what activity will be a value for you. You set goals on how to do that activity more. As you do more of that activity, you feel better as the result of the activity. Due to the reinforcement, you do more of that pleasurable value-oriented activity. If you can do it over time, it will result in lifting your mood and improving your self-esteem.
Behavioral activation will also help reduce feelings of learned helplessness. As you achieve your goals and do more activities that are meaningful to you, you developed self-efficacy. This means that you developed a feeling of "I can help myself". You relearned that you are no longer helpless and trapped. By doing that, you break the vicious cycle of depression.
For example, if a person values exercise, he can discuss with his therapist about doing some exercises. He can set goals for the week and his therapist can help him to become accountable. He plans out to exercise according to a schedule. When he feels depressed, he generally stays at home and ruminates about his failures. With the new plan, he is encouraged to exercise to keep his mind and body healthy. If he can reach his goals, it will lift his mood and he will be able to learn that he can help himself. Sometimes, the therapist can also help by motivating him.
In conclusion, there are many interventions available for depression. Although things may feel hopeless, it is temporary, it is normal for people to get stuck in depression and to need professional help to unstuck themselves.
In the article above, we shared some things you can do to help yourself with depression so that you can help yourself to reduce your suffering from depression. However, these techniques are not a substitute for real therapy. If it doesn’t work for you, help is always available. Understand that you are not alone. A therapist that has experience helping people with depression can help guide you out of depression.