With each passing year, more and more people can relate to the experience of struggling to get out of bed, the dread of having to face another day. If you haven't been paying attention to the statistics, it’s no secret that depression is on the rise. Quite literally, we are hearing about this crisis everywhere. Prominent news outlets like the New York Times and the Washington Post have covered the subject extensively in recent years. A quick search on each of their websites returns over 5,500+ articles that include the word depression. Would it be a stretch to say that feeling depressed or suffering from bouts with depression are as prevalent as the common cold in modern-day culture? We think not. But for some, depression isn’t just a circumstantial event or a seasonal downturn that happens with the changing of the weather (as painful as that can be). It is a diagnosable condition known as Major Depression Disorder (MDD) or Clinical Depression. One Reddit user who was diagnosed with Clinical Depression explains, “It isn't just sadness--it's a lifestyle based in a mood that moves between apathy to horrifying sorrow.” This tormenting reality is masterfully put on display by Zendaya in the critically acclaimed HBO hit Euphoria. In Episode 7 of Season 1, titled "The Trials and Tribulations of Trying to Pee While Depressed", her character Rue struggles to get out of bed for days, even to simply pee. In one scene shown here, she reflects, “you try to find yourself remembering the things that make you happy. But slowly, your brain begins to erase every memory that brought you joy. And eventually, all you can think about is how life has always been this way. And will only continue to be this way.” Over 17 million people are currently diagnosed with MDD, which means an astonishing 7.1% of the adult population suffer with this condition. All of this amplifies the need to properly understand depression from all angles. Statistically speaking, either you or someone you love will struggle with this within your lifetime. So as we dive deeper in this conversation, our starting point is understanding what classifies as depression to begin with.

Similar to the dynamic between trauma and PTSD, the difference between more common experiences of depression and clinical depression is muddied. Because the term “depression” is so casually thrown around, everything seemingly gets lumped together in one big mess. How do we tell the difference between momentary sadness and clinical depression? From burnout and clinical depression? Or seasonal depression and clinical depression?  Put simply, it exists on a spectrum. And understanding this spectrum is not only important towards understanding what you (or a loved one) might be experiencing in any given season, but also for knowing how to respond. Starting with major depressive disorder, Harvard says “the most prominent symptom is a severe and persistent low mood, profound sadness, or a sense of despair.”  They add that, “the symptoms of major depression are defined as lasting at least two weeks but usually they go on much longer — months or even years.” Feeling sad or distressed is a normal reaction to the traumatic and unsettling events of life. You may even find yourself feeling situationally depressed. And that is nothing to blink at. These crises must be responded to with an intense amount of care.  But clinical depression is not the same thing.  One psychologist explains in the Washington Post, “unlike everyday sadness, clinical depression is never a normal response to stress or trauma; it’s a serious medical illness that is associated with significant impairment in our ability to function in major areas of our life — in relationships, at home and at work.” Things that used to bring joy now don’t anymore. Even though life is filled with ups and downs, those with clinical depression only experience it in the downs. As seen with Rue’s character in Euphoria, everything becomes slower, dimmer and harder to get through.  As one Reddit user expounds, “Painful sorrow, loneliness, self-loathing, guilt, and occasional bouts where you are so far gone that you just go numb. Life, death, it's all the same after a while…you lose the one thing that most people might have had at that point: hope. ” In recent years, the difference between being burned out and severely depressed has come into question. As the New York Times observes of burnout, “the exhaustion, when it hits, is all-consuming. Your inbox chimes and you want to fling your phone across the room. You’re sick of your apartment; you can’t stand to leave your apartment. You fumble for the right word: You tell friends you are tired or fried or just done.” So is this the same thing as clinical depression? Not exactly. Stepping away from work in the short-term can alleviate this distress. You may find joy in being with friends, watching an episode of your favorite TV show or going out to eat. Depending on the severity of burnout, the joy might take some time to kick in. But eventually, it likely will. Especially in the medium-term, if you decide to quit the problemsome company. With major depression, it’s not like this. The sufferer may feel like no matter what they do, their state of mind doesn’t improve. The aforementioned Reddit user adds, “no matter how strong you are, no matter how bravely you try to face the world (more out of habit than anything else), the world erodes away at it all. Part of you fights against it so hard, but you're throwing punches at fog bank: the world just shifts into a new way of wearing you down. You can't stay tough against it forever. You're only human.” If this represents the rock bottom of depression, it’s helpful to highlight some other common categorizations that exist across the spectrum. They are as follows:  Major Depressive Disorder (Clinical Depression): What we’ve been primarily covering to this point. As Harvard puts it, “the most prominent symptom is a severe and persistent low mood, profound sadness, or a sense of despair… the symptoms of major depression are defined as lasting at least two weeks but usually they go on much longer — months or even years.” Persistent Depressive Disorder (Mild Depression): Less severe than major depression, the APA defines PDD as a depressed mood most of the time for at least two years. Often underreported and undiagnosed, it’s known as more of a high-functioning depression. Many of the symptoms are similar to MDD, but the ability to carry on a normal life is easier. Seasonal Affective Disorder (Seasonal Depression): As you can infer from the name, this type of depression is directly tied to the seasons, mostly commonly experienced in winter months. When the sunlight returns in the summer, a positive mood also returns. Postpartum Depression: Most common for newborn mothers in the weeks and months that follow giving birth, men can also experience this type of depression. While shame tends to be present in many forms of depression, especially MDD, it’s a hallmark feature of Postpartum. Feeling like you are “supposed” to be happy in this season only creates extra pressure. Situational Depression: Not technically a clinical diagnosis, it’s helpful to include this to circle back on what we covered above. Stressful life events can make you feel depressed and this should be taken seriously. The way that someone deals with situational depression can often influence their mood in the medium and long-term, whether positive or negative. Burnout: Also not a clinical term just yet, Harvard says that burnout “is a three-component syndrome that arises in response to chronic stressors on the job, [including] exhaustion, cynicism and inefficacy. In a separate blog, we covered burnout extensively.  Bipolar Disorder: We talked about Bipolar extensively in another blog, but it’s helpful to add to this list because of the depressive component involved. As Harvard puts it, “bipolar disorder is a mental disorder characterized by wide mood swings from high (manic) to low (depressed).” Bipolar is commonly classified in three types: Bipolar I, Bipolar II and Cyclothymic Disorder. While these categorizations are helpful from an educational standpoint, it’s also easy to get overwhelmed by all of the possibilities. So it's important we circle back on the main point here.

There’s a spectrum of depression that exists, influenced by a number of factors.

For the purposes of this blog, we’re going to cover clinical depression more deeply. But ultimately you’ll discover below that the way you’d respond and treat clinical depression bears similarities to the other forms of depression.

If depression exists on a spectrum, naturally the next question would be... how does clinical depression manifest? What causes something so severe to take root in one’s brain? And why is it that some experience mild depression, while others have more drastic downturns? We previously covered this in our blog on the root causes of mental health issues, but there’s a predominant narrative in our culture that goes a little something like this: Mental health issues are primarily genetic and/or a result of a chemical imbalance within our brains. When we put forth this theory, we are essentially communicating that mental health issues are an inevitability, not a possibility. It’s a destiny that some of us are simply fated for, if only because it’s within our genes. But the truth is like many other mental illnesses, depression does not have one singular cause, but rather a variety of factors that influence the onset of the disorder.  Here’s what Harvard has to say about depression specifically: “It's often said that depression results from a chemical imbalance, but that figure of speech doesn't capture how complex the disease is. Research suggests that depression doesn't spring from simply having too much or too little of certain brain chemicals. Rather, there are many possible causes of depression, including faulty mood regulation by the brain, genetic vulnerability, and stressful life events. It's believed that several of these forces interact to bring on depression.” So depending on the individual, the severity of depression will come down to a cocktail of factors. For example, that equation could look like:  Stressful life event + personality type + low serotonin = severe clinical depression But for another individual, they may have the same risk factors, yet experience mild depression. Whatever the case, when trying to assess the onset of clinical depression, a doctor will look at two main variables: how intense the depression is and how long it’s gone on for.  They’ll look to rule out other diagnoses that could be confused with clinical depression such as OCD or as we mentioned before, Bipolar Disorder. Finally, they’ll look to confirm at least five of the following symptoms:

• • Loss of interest in activities that previously were enjoyable
  • Weight gain or weight loss
  • Sleep increase (hypersomnia) or decrease (insomnia)
  • Feelings of worthlessness
  • Feelings of guilt and shame
  • Interruption in work activities; struggling to concentrate
  • Low energy; fatigue that sets in regularly
  • Irritable mood and agitation
  • Both emotionally and physically, feeling slow
  • Ongoing thoughts about suicide and death

 With persistent depressive disorder (mild depression), doctors will look to confirm at least three of these factors, in addition to the severity and length of the symptoms.

To further complicate matters, social dynamics can be incredibly tough for those with clinical depression. It’s natural to start isolating yourself, to stop answering texts, to not show up to social events and/or behave differently around those you are close to. Because one part of the population does not know what it is like to be severely depressed, they can’t relate to the experience and don’t know how to support the sufferer. They’ll often respond in ways that are unhelpful, reductionist or worse, don't talk about it at all. If those around you don’t properly support you through a depressive episode, this can make matters much worse, creating a cycle of shame and loneliness. One Reddit user puts it this way: “Because nobody talks about it, you must eventually conclude that there must just be something wrong with you: you're a problem and you need to fix it. You were the one who didn't interact with your friends, your the one who can't find enjoyment, you're the one who can't handle what's going on in your life, you're the one continuing to make stupid mistakes because you're tired. So, really, it's all your fault. If you're depressed, it's because you're a screw up. So, toss guilt and the need to second-guess and overanalyze everything you need to do into the mix, and overanalysis to the point of increased shame and guilt is really easy to do in the sleepless nights and friendless free time.” This only adds to what feels like a suffocating existence of loneliness and despair. Worse, many others feel like they aren't blessed with a supportive circle to begin with. For all of these reasons, this makes an informed and educated approach to treatment even more important.

When you’re in the middle of it, dealing with clinical depression can feel utterly hopeless. Like there’s no way out. In the worst downturns, it feels like life is defined by nothing other than daily despair. But despite this persistent state of gloom, the prognosis can be very good. Clinical depression is highly treatable, meaning your reality today doesn’t have to be your reality tomorrow. It may not feel that way and the road to recovery definitely won’t be easy, but this doesn’t make it any less true. There are a couple breakthrough treatments at our disposal that have shown to be highly effective for depression, which significantly improve quality of life.  Psychotherapy has helped with the “nurture” side, that is depression heavily influenced by life events and circumstances. Medication primarily works on the “nature” end, related to genetics, brain circuits and chemical imbalances.

Included within that larger umbrella of psychotherapy treatments is cognitive behavioral therapy (CBT). Harvard defines CBT as, “A highly effective psychotherapy [that] focuses on how our thoughts, beliefs, and attitudes can affect our feelings and behavior.” It’s based on the idea that much of reality is shaped by our thoughts and feelings, not externally facing circumstances or variables, like people, situations or events. The benefits of CBT help us better cope with circumstances, even if the externally facing variables don’t change. This is critical for those who feel like giving up or believe that depression will never get any better.  Proponents of CBT are quick to point out that CBT is not merely about positive thinking, but rather realistic thinking. How do we interpret the events that happen within reality, both negative and positive? As one psychologist put it:  “The goal with cognitive therapy is to make sure someone has an accurate assessment of the situation. Some situations are genuinely awful, and a negative belief about them makes sense. Some situations are truly good, so a positive thought is accurate.” Of course, central to the idea of CBT would then be how you make sense of the world.  How do we define what’s accurate, genuinely awful or truly good? How do we make sense of suffering, our experiences and the ways people have hurt us? Clearly, it can’t just be based on feel-good emotions.  Dr. John Gottman, one of the most influential psychologists in the world, details in his book The Science of Trust how women have told him some of the best sex they experienced was directly after physical abuse. We see this exact scenario play out with Nicole Kidman’s character in the critically acclaimed show Big Little Lies. But as we witness in the show, it’s doubtful any psychologist would encourage women to lean into their positive emotions in this scenario and view these experiences as “truly good”.  Objectively speaking, in any culture, there’s something deeply troubling about physical abuse. So CBT works best when we align ourselves with objective truth and understand how the world actually works. Thousands of years before the modern roots of CBT, Jesus gave us a foundational paradigm for how to view our experiences.

1. 1. There is a Creator who designed a perfect world, but humans only have a limited lens into the nature of reality.
   2. Since the beginning of time, something (clearly) has gone horribly wrong, springing about everything from wars and disease to death, mental health issues and racism.
   3. Humans are flawed and play an active role in hurting each other, infected by a condition Jesus labeled חטא (sin), which in its simplest form, means to miss the mark. Think in terms of archery, to which we are essentially missing the bull's eye on God's original design to both love him and love each other.
   4. Jesus claimed to be the primary means himself in which all things are being restored to their original condition, inviting us to follow his way of life. 
   5. In the present day, we live in a time period of the “now” (present healing, reconciliation and beauty) and “the not yet” (future and final healing and reconciliation).

 Whether we realize it or not, aspects of this paradigm have undoubtedly influenced modern-day psychology and the way we approach CBT. For a therapist to even guide a patient into an “accurate assessment” of the situation, requires them staking claims to what’s “genuinely awful” and “truly good”. It requires an acknowledgement that things aren’t as they should be and that humans do play an active role in hurting one another. It requires walking their patient through how to cope in the midst of suffering, to live between the healing available “now” and the hope of the “not yet”. And hereby is the importance of aligning ourselves with how the world (objectively) works when practicing CBT.  When it comes to treating depression, putting CBT into motion might involve helping the patient challenge that worsen the depression. Thoughts like it's always going to be this way. Or there's no point in going to my friend's house, because I'll have a bad time and just be depressed there. It may involve the shame and self-criticism that arises from a relationship breakup. Or perhaps it’s helping a father navigate the loss of a child and thoughts of “there’s no point in living”. Most importantly, CBT helps the sufferer through the mountain of cognitive distortions that have been built up from the depressive episodes, retraining the mind to think differently.  Many have found Jesus’s take on suffering to be the most helpful and transformative in all of history. Jesus and his followers knew that suffering (dealt rightly) can produce perseverance, which in-turn will make us complete as human beings.  Why is it that we always enjoy the underdog story? Why is it that the most compelling narratives in film are often the tragedies that turn into triumphs? It’s because this simple truth is woven into the fabric of our existence. Time and time again we learn that to get the best results out of CBT, we have to get an accurate assessment of the situation. As we’ve observed, we do-so by aligning ourselves with how the world actually works and let everything else flow out of objective truth. To which Jesus says this to his followers: “Therefore everyone who hears these words of mine and puts them into practice is like a wise man who built his house on the rock. The rain came down, the streams rose, and the winds blew and beat against that house; yet it did not fall, because it had its foundation on the rock.”

As a technique that is part of CBT, behavioral activation works to actively fight against “the depression spiral” many sufferers find themselves in. When the depressed mood and low energy comes on, the first instinct is to isolate and do nothing, waiting to feel better. Behavioral activation takes a proactive approach, understanding that the objective truth in this dynamic is that being active first will in-turn influence your depressed mood. While we can’t influence the mood to begin with, we can choose how to respond and this is incredibly important, especially for severely depressed individuals. This first step here would be evaluating your current schedule to get a sense of what you are doing too much of and too little. Your therapist will walk you through a “values assessment” to get a sense of what you value and enjoy in life. And you begin to schedule out activities, comparing your mood before and after, with a focus on celebrating the accomplishment of completing the task to begin with. For one person, this may mean returning to the gym once or two a week after not going at all for a period of months. For some, the temptation is to be self-critical while engaging with behavioral activation. In the previous example, you may hyperfocus on the fact you only went to the gym twice, instead of everyday, so this means treatment isn’t working and now you’re a failure. Which goes to say, when engaging in this practice we have to be wary of “I should statements”, which is yet another cognitive distortion.

Another form of psychotherapy is interpersonal psychotherapy (IPT). Remarkably, research has shown that this is just as effective as medication in treating depression. Rather than starting by addressing specific thought patterns and behaviors like CBT, it focuses on a higher level with the relationships that may partially be at the root of the depression. This may include the beginning of ending of relationships, past relational difficulties, an ongoing struggle in a relationship or a perceived relational deficit, like not getting married.

As we mentioned above, psychotherapy primarily focuses on the “nurture” side, that is depression heavily influenced by life events and circumstances. Medication primarily works on the “nature” end, related to genetics, brain circuits and chemical imbalances. Antidepressants (SSRIs) such as Luvox, Zoloft, Prozac, Paxil, Celexa and Lexapro are the most commonly used medications in conjunction with psychotherapy.  But most therapists would advise that medication is not a replacement for psychotherapy, rather a supporting character for treatment. If you are thinking about taking medication, here are a few things to consider before moving forward:

1. 1. Avoid making this decision on your own. Consult with your therapist and come up with a comprehensive game-plan on how to treat your depression first. 
   2. Educate yourself on medication. Scientists still aren’t exactly sure why SSRIs work, only that they do. It’s thought that they increase serotonin levels in the brain. SSRIs are generally considered safe, but given that they’ve only been in existence for a few decades, it’s difficult to know the long-term side effects. 
   3. Medication isn’t a cure-all. It’s shown to be 40-60% effective in reducing symptoms, which means some people won’t benefit from them at all. The process may also require trying different medications, as some work better than others based on the individual.
   4. SSRIs often come with unwanted side effects, such as elevated cholesterol, weight gain, lowered libido and insomnia, amongst other things. 

 A closing thought on the medication conversation:  There’s often a stigma associated with taking medication, but it’s time to question why that is. If someone was taking blood thinners to prevent blood clots, would that be frowned upon? How about insulin for type 2 diabetes? Or how about the eight oral medications typically used for multiple sclerosis? Ethnic stereotypes, religious dogma and misinformation have often been the culprits of the deep shame caused when we’re faced with the dilemma of whether to take medication or not. It’s time we rewrite the narrative, namely that it does not mean someone is weak, incapable or less “spiritual” because they are dedicated to go down this route.

So where does this leave us? The numbers suggest that about 17.3 million adults (7.1% of the adult population) have been officially diagnosed with Clinical Depression in the United States.

But because this is only including those that are diagnosed, it’s likely that many more people are affected than the numbers reveal, especially when it comes to mild depression.

It is one of the many disorders causing a meteoric rise in mental illness in recent years, which we covered in a previous blog. But despite this rise, there are significant concerns around the lack of government funding towards mental health, accessible mental healthcare, affordable mental healthcare and quality mental healthcare. It’s been widely-documented that the healthcare system is essentially set-up to be a continuous loop of reactiveness and symptom-management, both for physical and mental illness.  We must ask the troubling questions – why does the government fund what they do? Why are controversial drugs being given a stamp of approval? Is there genuine concern about helping and healing people? Or is something else the motivating factor? In 2021, a group of Yale professors penned an op-ed in the Washington Post entitled, “The FDA is in desperate need of soul-searching”, in which they outline how the FDA has fallen into bed with Big Pharma. It’s a common occurrence for FDA officials to swap roles with those on the boards of Big Pharma companies, such as Biogen. These are clear injustices and red flags that exist within the current operating system.  So if this is the case, where do we find our hope on the long-term outlook of clinical depression? Is it in medication initially to cope? Is it in finding a great therapist? Or navigating the complicated and conflicting governmental factors to achieve success? These are all certainly parts of the equation, important and complementary aspects of our healing journey. But in our view the starting point of healing begins with taking a step back and considering how what you believe about the world affects your mental health.  We covered this in our blog on the root causes of mental illness, but we all live our lives by an ideology, which is a “a system of beliefs that we carry which shapes the way we interact with the world around us.” Whether we realize it or not, what we believe about the nature of reality, about God and about ourselves heavily influences the way we approach our depression journey. In this regard, we’re big proponents of the way of Jesus as the best foundation to make sense of the world. The way of Jesus proposes that healing is a holistic journey, made up of spirit, mind and body, with everything intertwined like a web. The way of Jesus helps settle the existential questions of the heart, like the meaning of life, our role in the world and the purpose of suffering, making healing a far less lonely journey as we get to walk side-by-side with the one who made us. Clinical depression may be a big burden to bear, but settling our set of beliefs and then engaging with tools like CBT, behavioral activation and if needed, medication, have statistically shown to be a huge catalyst towards healing for many.  This doesn’t mean the process won’t be painful. Healing often requires hard work.  But the tools are at our disposal for our tomorrow to be much better than our today. For more, click here to visit our Mental Health Hub.