By Kirstin Fawcett for U.S. News
To say Rachel Hargrave has experienced "depression" is a bit simplistic. Thirteen years ago, Hargrave -- now a 32-year-old mother and psychology student who lives in Sabina, Ohio -- gave birth to her daughter. A month later, she recalls, "I felt like I hit rock bottom. I couldn't get off the couch. I couldn't bathe. I couldn't do anything." Hargrave visited her doctor, who prescribed her medication. Neither of them knew, however, that her lifelong struggle had only just begun.
Instead, her crippling sadness "never went away," says Hargrave, who responded poorly to multiple types of medication and now says she alleviates her symptoms with vitamins and exercise. "It comes and goes with the seasons."
Hargrave's story illustrates the complexities of depression -- a mental health condition that's as multi-faceted as its name is vague. The word "depression" itself is a loose term for multiple diagnoses, each with a differing range of symptoms and treatments, experts say. And due to a lack of education or awareness, many people don't know there are variants of depression, or that one person's symptoms of depression might not mirror another's.
"They don't realize depression comes in many different faces," says Edward Hunt, a District of Columbia-based therapist who works in private practice. "When they come to me, most of my clients only know they are hurting. They don't have an adequate grasp of what is causing the pain or how to make it stop. Some only know about medications. Some only know about what they heard about in Psychology 101, or what their high school counselor said that one time during assembly in the gym. But all of them want relief."
In Hargrave's case, she's dealt with both seasonal affective disorder -- a subtype of depression that ebbs and flows with the changing weather and light levels -- and postpartum depression, another subtype that occurs during pregnancy or within four weeks of delivery. Her experiences are relatively common, and only represent a small swath of the spectrum.
The Most Common Type Of Depression
In the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), depression is divided into several subsets. The most commonly diagnosed form of depression is major depressive disorder, which is typically defined by symptoms such as "depressed mood, loss of interest, weight loss [and] loss of energy for at least two weeks continuously," Hunt says.
Major depression affects about 6.7 percent of the U.S. population over age 18, according to the National Institute of Mental Health -- although women are 70 percent more likely to be diagnosed with major depressive disorder than men. There's no clear-cut cause for major depressive disorder, although doctors think it could stem from anything from traumatic life events to brain chemistry, genetics and hormones.
However, even people with major depressive disorder might experience their "depression" differently than someone with an identical diagnosis. Four years ago, Michael Miller, a 32-year-old poet and part-time college administrator in Newark, Delaware, discovered he had major depressive disorder.
"[I had] insomnia, irritability, a tendency to draw inward and away from friends and family," Miller remembers. "Leaving the lights off and just crawling back into bed, or sitting behind a screen and filtering life through the Internet if at all possible. Just a lack of interest in doing anything - like ennui on steroids."
Miller often self-medicated with alcohol. Detailed thoughts of suicide ran through his brain. And in the spring, his depression would suddenly lift, filling him with a newfound energy. "There's a seasonal affective component to major depression, which is why I for a time thought I might be bipolar," he says -- a psychiatric condition that the DSM-5 separates from depression and is characterized by moods that swing from extreme lows (depression) to highs (mania). "In the spring, I'll suddenly feel awesome and write a lot.
Nevertheless, Stephanie Rosen, 34, encountered a different set of symptoms when she first experienced major depressive disorder. Rosen -- who now works for the National Alliance on Mental Illness, a national grassroots advocacy and education organization -- was a student in medical school when she realized she was sick. "I was sleeping about 12 hours a day," she says. "I was having actual paranoid thoughts. I would check my apartment multiple times before being able to go to sleep because I was convinced there was someone in there -- even to the point that I was checking kitchen cabinets. I had a lot of crying, a lot of distorted [ruminations] -- that nobody liked me and nobody was talking to me." Rosen also gained weight, had trouble making decisions and couldn't concentrate on her studies.
It's normal, Hunt says, to undergo a subtype of depression in one's own unique way -- even if the medical label is the same as someone else's. "The most confusing thing about the blanket term 'depression' is that some presentations appear to be completely polar opposites," he says. "Some people may not sleep. Some people may not be able to get out of bed. Some people may not eat, some may not be able to stop eating; some people may become increasingly restless, while others barely have the energy to read."
Less Common Subsets Of Depression
While major depressive disorder is the most well-known type of depression, others exist as well. Like Hargrave, many women -- an estimated 9 to 16 percent, according to the American Psychological Association -- get postpartum depression after giving birth. (Postpartum depression might be caused by a combination of stress, a lack of sleep, family susceptibility for depression and/or chemical changes in the brain when a woman's estrogen and progesterone levels drop after childbirth.) And in both Hargrave and Miller's cases, they had forms of seasonal depression -- a specifier that refers to when a person's major depressive episodes regularly occur during a particular season, particularly in the fall and winter.
However, several less common subtypes remain. One type, persistent depressive disorder -- formerly called dysthymia -- is "a type of mild chronic depression that lasts from two to five years," says Arif Khan, an adjunct professor of psychiatry at Duke University School of Medicine and medical director and principal investigator at Northwest Clinical Research Center in Bellevue, Washington.
Persistent depressive disorder appears very similar to major depressive disorder -- losing interest in normal daily activities, feeling hopeless and worthless and experiencing lessened productivity. However, it's less severe; it stretches for longer durations and fewer people are diagnosed. "While the prevalence of [persistent depressive disorder] is somewhat controversial, it could be anywhere from 1 to 3 percent [of the population]," Khan says.
Another depressive disorder -- which was recently added to the revised DSM-5 -- is premenstrual dysphoric disorder, or PMDD. With premenstrual dysphoric disorder, Hall says, women "experience one or more mood swings, marked irritability, marked depression, marked anxiety and/or decreased interest, lethargy, change in appetite, change in sleeping habits, sense of being overwhelmed and physical symptoms." Various studies estimate that 3 to 8 percent of women meet the criteria for PMDD. Although the exact cause isn't known, scientists believe PMDD is spurred by hormonal fluctuations during menstruation.
According to the DSM-5, there are more subtypes in the DSM-5 that differentiate between types of depression with unique features. For instance, depression can have mixed features -- i.e., sadness with bouts of mania, or extreme highs. It can have melancholic features, which means the depressed person loses pleasure in almost all activities. And it can have psychotic features, in which there's a presence of delusions or hallucinations.
Depression isn't just diagnosable in adults, either. Disruptive mood dysregulation disorder is a new classification in the DSM-5 -- a diagnosis for children between the ages of 6 and 18, Hunt says, who "display a variety of symptoms surrounding the inability to effectively manage their emotions -- more so than a typical child in the same developmental stage." This subtype was created to help clinicians describe a child's depression without prematurely diagnosing him or her with bipolar or some other disorder, Hunt adds.
Treatments For Depression
There's no one type of depression -- and therefore, there's no one type of treatment. However, there are some common tools used for relief. "The general treatment for major depressive disorder is medication," Khan says. "The more severe [the patients' depression is], they more they're likely to respond to antidepressants." Many people also respond to various types of therapy, he points out, including cognitive behavioral therapy.
For treatment-resistant depression, Khan says, electroconvulsive therapy -- a procedure in which electric currents are passed through the brain, inducing a brief seizure that can cause changes in brain chemistry -- is an option. Another similar option is vagus nerve stimulation, a surgery in which a doctor implants a pacemaker-like device into the body that sends pulses of electricity. The electricity travels through the vagus nerve into the brain, where it helps control mood. And physicians, Khan says, are also still exploring the effects of transcranial magnetic stimulation -- a relatively new procedure that uses magnetic fields to stimulate nerve cells in the brain to lessen depression.
"Things like exercise can also have a good effect," Khan adds. "But they key is to get into some sort of treatment - visit your doctor, visit a psychologist. That's the best indicator of prognosis."
Still, says Hargrave -- whose experiences inspired her to enroll at Capella University, where she's studying to receive her master's and doctorate degrees in psychology -- everyone has their own coping mechanisms for depression ... no matter what their diagnosis might be.
"Each person has a different personality," she says. "So they have to figure out what works for them. Read about it; get pamphlets about it; do research about it. And don't take it for granted. It is an actual disease. It's not up in your head."