Written by a board-certified psychiatrist and an international expert on self-management of depression, this blog focuses on proven scientific methods of treating depression that go beyond medications and traditional therapy. It discusses elements of healthy lifestyle, positive psychology, relationships, communication, and wellness. The content of the blog is not to be construed as treatment advice.
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What Depression is Not
When one is feeling low, it doesn’t necessarily mean
that one is going through the throes of clinical depression, i.e., major
depressive disorder. There are several conditions that may mimic clinical
depression but don’t reach the severity or pervasiveness of the former
condition or are symptomatically distinct. It is important to recognize these
so that one may not unnecessarily get prescribed medications or started on
psychotherapy as some of these conditions are time limited or may remit on
their own. At the same time, some of these conditions such as complicated grief
may need specialized therapy. Conditions that resemble depression
but are not depression include the following:
is more than the normal pangs of sadness one gets when experiencing a stressful
situation. Depression is a more pervasive and persistent change in your mood
along with changes in your physiological functions such as sleep, appetite, and
energy level. Although stress can trigger a depressive episode, not everyone
faced with stress becomes depressed. And, sometimes depression can occur
without any specific triggers and may not respond to changes in environment
(the so-called endogenous depression), which differentiates it from sadness.
Moreover, while sadness can disrupt your day-to-day functioning, the effect of
depression is more significant, though some researchers believe that this
criterion is not clinically meaningful to distinguish sadness from depression
(Wakefield et al., 2010). In contrast to sadness, depression is associated with
a pattern of negative or distorted thinking which perpetuates the symptoms
and depression have a complex relationship. The Diagnostic and Statistical Manual of Mental Disorders – fourth
edition, text revision (DSM-IV TR) excluded depressive symptoms occurring up to
a couple of months after a loss as being a sign of a major depressive episode
(American Psychiatric Association, 2000). However, depression arising after a
loss of a loved one is no different compared to that arising due to a job loss
or recent divorce or “out of the blue” (Pies, 2014). Moreover, not diagnosing
depression during grief can potentially divest such people from getting timely
help; professionals may defer treatment until symptoms persist or become more
severe. In tandem with these observations, the DSM-5 doesn’t consider bereavement as an exclusion for diagnosing
Certain symptoms may help one distinguish when
bereavement may have transformed into depression (American Psychiatric
Association, 2013). These include persistently sad mood that doesn’t improve
with changes in environment, lack of pleasure, feelings of worthlessness,
pessimistic or self-critical ruminations, and suicidal thoughts related to
negative feelings about self.
grief: Another condition called complicated grief or as the DSM-5 calls it, the “persistent complex
bereavement disorder,” also mimics depression. In short, this is characterized
by preoccupation with the deceased or the circumstances related to death,
feelings of disbelief or numbness, excessive avoidance of reminders of the
loss, a desire to die in order to be with the deceased, social withdrawal, and
persistence of other intense and impairing symptoms of acute grief beyond the
socially and culturally accepted norms (American Psychiatric Association, 2013;
Shear, 2015). Complicated grief differs from depression as it an extension of
the normal grieving process and
usually lasts more than a year while depression is a clinically diagnosable
entity. Approximately, 7% of grieving individuals develop complicated grief.
Women and those with preexisting mental illness, substance use, trauma history,
limited social support, and multiple recent losses are more at risk of
complicated grief (Simon, 2013). Screening tools such as the Inventory of
Complicated Grief can help people with prolonged grief arrive at a proper
diagnosis (Prigerson et al., 1995). Although, antidepressants have been used to
treat complicated grief, it is best treated with focused psychotherapy.
disorder with depressed mood: Stressors – breakups, job
loss, marital conflict, natural disasters, or life changes such as school,
illness, marriage, divorce, retirement, etc. – can cause a heightened emotional
or behavioral reaction in some people. If you experience low mood, tearfulness
or feelings of hopelessness within three months of a stressful situation and
these symptoms subside after the stressor is over, the diagnosis is more likely
to be adjustment disorder with depressed mood (American Psychiatric
Association, 2013). Compared to depression, adjustment disorder always has a
clear precipitating event, is time limited, and never meets the full criteria
for depression. Psychotherapy is the mainstay of treatment for adjustment
disorder with depressed mood.
syndrome and premenstrual dysphoric disorder: Premenstrual
symptoms, starting a week before the onset of menstrual cycle, range from mild
physical or behavioral symptoms in premenstrual syndrome to marked mood changes
– irritability, crying spells, depression, and anxiety – in premenstrual
dysphoric disorder. The latter is also characterized by changes in sleep,
appetite, lack of interest, difficulty concentrating, increased sensitivity to
rejection, and physical symptoms such as feeling of “bloating,” breast
tenderness or swelling, or joint/muscle pain. The symptoms in premenstrual
dysphoric disorder are severe enough to interfere with normal functioning.
However, unlike depression, the symptoms subside after the onset of menses and
don’t represent an amplification of pre-existing depressive symptoms (American
Psychiatric Association, 2013).
To learn more about evidence-based
self-management techniques that are proven to work for depression, check out
Dr. Duggal's Author
Page. To find out if you have clinical depression, check this blog post.
HARPREET S. DUGGAL, MD, FAPA
American Psychiatric Association (2000). Diagnostic and statistical manual of mental
disorders (4th ed., Text Revision). Washington, DC: American Psychiatric
American Psychiatric Association (2013). Diagnostic and statistical manual of mental
disorders (5th ed.). Arlington, VA: American Psychiatric Association.
Burns, D. D. (1999). Feeling good: The new mood therapy. New York, NY: Avon Books.
Pies, R. W. (2014). The bereavement exclusion and
DSM-5: an update and commentary. Innovations
in Clinical Neuroscience, 11(7-8), 19-22.
Prigerson, H. G., Maciejewski, P. K., Reynolds III, C.
F., Bierhals, A. J., Newsom, J. T., Fasiczka, A., Frank, E., Doman, J., &
Miller, M. (1995). Inventory of complicated grief: a scale to measure
maladaptive symptoms of loss. Psychiatry
Research, 59, 65-79.
Shear, M. K. (2015). Clinical practice. Complicated
grief. The New England Journal of
Medicine, 372(2), 153-160.
Simon, N. M. (2013). Treating complicated grief. The Journal of American Medical Association,
Wakefield, J. C., Baer, J. C., & Schmitz, M. F.
(2010). Differential diagnosis of depressive illness versus intense normal
sadness: how significant is the “clinical significance criterion’ for major
depression? Expert Review of
Neurotherapeutics, 10(7), 1015-1018.
Procrastination is putting off things for another day,
or doing things which are not productive as an excuse of not doing what is
important. Dr. Wayne Dyer (1995) in his book, Your Erroneous Zones, provides the rationale behind procrastination
as a thought process which is something like this: “I know I must do that, but
I am really afraid that I might not do it well, or I won’t like it. So, I will
tell myself that I will do it in the future, then I don’t have to admit to
myself that I am not going to do it. And it is easier to accept myself this
way.” This temporary avoidance gives you a quick relief from the anxiety
associated with a task, which then reinforces this behavior. We all have
procrastinated at one time or the other, but in depression, procrastination
becomes more complex due to the self-defeating attitudes of perfectionism (“I
can do things only if I can do them perfectly”), hopelessness (“My low
motivation and low energy levels are never going get better”), and fear of
Anger, irritability, and frustration may not be the
core symptoms of major depression in adults, but almost 50% of people with
major depression experience these symptoms (Fava et al., 2010; Judd et al.,
2013). In addition, irritability may be the main presentation of mood in children
and adolescents with depression. Having irritability and anger while being
depressed is a double whammy. Overt irritability and anger during an episode of
major depression is associated with greater severity of depression, longer
duration of the episode of depression, poorer impulse control, a more chronic
and severe long-term course of depression, higher rates of lifetime substance
use and anxiety disorder, and greater psychosocial impairment (Judd et al.,
2013). When feeling depressed, you may be masking your more vulnerable feelings of hurt, guilt,
shame, grief, or fear with anger or irritability. Depression causes the emotions
that make you feel more vulnerable not come to the surface as you are uncert…