October 10th is World Mental Health Day.
If you have never experienced depression, it can be hard to comprehend. And even if you have had overwhelming bouts of sadness, you may not realize that clinical depression is a whole other beast. Major depressive disorder is more than just feeling down or low sometimes, so what is depression?
The National Institute of Mental Health reported that 2016’s National Survey on Drug Use and Health (NSDUH) found that approximately 16.2 million U.S. adults have had at least one major depressive episode. The study found that women experienced more depressive episodes than men, and the rate of depressive episodes was higher for people ages 18 to 25, as well as those who are two or more races.
Yet the study also showed that 37% of people who had a depressive episode never sought help. So we talked to clinical psychologist Dr. Elizabeth Cohen, Ph.D., who specializes in cognitive-behavioral therapy (CBT) and runs Elizabeth Cohen and Associates in New York City, about the invisible condition. Dr. Cohen explained not only what depression is, but how to know when you should get treatment, and what you can expect from therapy. And while she can’t prescribe medication as a psychologist, she also went over the role that antidepressants can play when it comes to your mental health. And if you think you might have depression, speak to a health care provider.
What is depression?
“In layman’s terms, depression is depression—it’s broad. As therapists, we have some distinctions. We came up with the Diagnostic and Statistical Manual (DSM) so that we can communicate across hospitals and across institutions. The definition for depression, according to the DSM, is you need to feel sad more days than not. For adults, you can be sad or irritable. And then you need to have five of the other symptoms.”
As the American Psychiatric Association (APA) notes, the other major symptoms of depression from the DSM are:
- Loss of interest or pleasure in activities once enjoyed.
- Changes in appetite—weight loss or gain unrelated to dieting.
- Trouble sleeping or sleeping too much.
- Loss of energy or increased fatigue.
- Increase in purposeless physical activity (e.g., hand-wringing or pacing) or slowed movements and speech (actions observable by others).
- Feeling worthless or guilty.
- Difficulty thinking, concentrating or making decisions.
- Thoughts of death or suicide.
Dr. Cohen also listed disinterest in sex, hopelessness, and chronic, physical pain as symptoms.
What are the other ways that depression can show itself?
“Social isolation. Not finding enjoyment in things that you used to enjoy. For example, you take pottery classes and you used to like it and now you go and you feel like it’s robotic. Things just don’t feel like they used to feel. People talk about it sometimes as a light that went out inside. Things feel dull.
“Also, feeling overly sensitive. A friend can’t make your birthday party and you think they hate you, so you overgeneralize your negative feelings about yourself or your negative self-image. Another thing is rejection sensitivity. A neutral situation happens and you think, ‘It must be because I’m terrible or that person is angry with me.’ With depression, a neutral situation is interpreted as negative rather than neutral or positive. So a friend says something to you and you interpret it as, ‘I’m bad,’ ‘I did something wrong,’ or ‘Nothing’s going to work out.’ That’s the underlying belief you have.”
— Dr. Cohen
What are some different types of depression?
“There is something called major depressive disorder, which is a distinct period of time where you feel sad—sad or irritable more days than not—and have these accompanying symptoms with the depression. There’s also something called dysthymia [persistent depressive disorder], which is a longer-term, chronic low mood. You don’t have a deep depression, meaning it may not be impacting you functionally as much. But you have a longstanding, low mood. You can have both, sadly. You can be having dysthymia (two years or more if you’re an adult and one year or more if you’re a kid). And then you can have a major depressive episode within that, which would be very painful.”
— Dr. Cohen
I’m not necessarily sad, but I am unhappy and angry. Could that be depression?
“Irritability, feeling very frustrated with people, and feeling a short fuse—that can be depression. If you have been feeling on edge and everything’s pissing you off, you don’t usually ask yourself, ‘Am I sad? Am I upset? Am I depressed?’ But they are good questions to ask. I often like to say to people, ‘What’s underneath the anger?’ And usually, very quickly, they realize there’s sadness. I have clients who come to me for anxiety and then after we work on the anxiety, this other depression piece comes. I’m not sure they’re so incredibly different, but be open to it morphing into different things.”
— Dr. Cohen
What are some signs that I should speak to a mental health professional about my depression?
“The biggest thing always for any sort of therapy is how much it is interfering with your life. There are two pieces. If you’re sad more days than not and, in order to have a diagnosis, it needs to be interfering with your functioning. That means friends are asking you to hang out and you are not because you’re like, ‘Eh, what’s the point?’ Or you’re at work and you have been having difficulty concentrating and your boss gives you some feedback that you just haven’t seemed to be on top of things lately. That is interfering with your functioning.”
— Dr. Cohen
But I don’t want to see a therapist. Why should I?
“What’s so insidious and difficult about depression is the way it presents is the complete antithesis to getting help. Depression is what we call an internalizing disorder. In depression, you feel so much lethargy, so much slowness, so much lack of interest in things that it’s counterintuitive to get the help that you need. Usually, people who come for help with depression are really far into their depression. Therapy is the opposite of what you want to do. It’s really hard to get self-motivated for treatment with depression.
“If you have a friend who’s saying you seem depressed, listen to them. Because one of the symptoms of depression is really losing your perspective on your own experience. You feel hopeless. So why would you ever think a therapist could help, right? But you can get yourself out of going into deeper, deeper depression by having some treatment.”
— Dr. Cohen
What causes depression?
“The biggest study done on depression is called the Epidemiologic Catchment Area (ECA). But we don’t really know. We haven’t been able yet to do too many twin studies to understand what’s nature and what’s nurture. As a clinician, I believe that it’s a combination of both. I have seen people who have full, joyful lives who are depressed because, I think, predominantly from having a genetic predisposition. And then I have people who have a genetic predisposition and have environmental situations that make their lives more difficult. Your environment isn’t necessarily going to make you depressed.
“In my opinion, it’s how you interpret things. And your interpretation can be based on how you were brought up. If you were brought up with a parent who was always focusing on the negative, never focusing on the neutral or positive, you’re going to learn that and you might also have a genetic predisposition.”
— Dr. Cohen
What are some good ways to find a therapist?
“Ask your friends if they have therapists that they’ve liked or to ask their therapist for recommendations. Meet with at least two, ideally three, different people. You are the consumer. This is not like you’re going to some expert who has all the answers and you just have to find the right expert. This is about the connection, the shared experience, and the shared trust between two people. So you have to feel comfortable. I can’t tell you how many people have come to me and said, ‘Well, I had a therapist and I didn’t really feel that connected to her and I don’t think she helped that much. I saw her for two years.’ That shouldn’t be happening. If you don’t feel connected to somebody, find somebody else. Everyone has different personalities. I always try to empower clients to know that it’s their decision. So meet with a couple of people and see how it feels.
“I think the hardest thing about therapy is that people are always afraid they’re going to have to talk about things they don’t want to talk about. Or that therapy is going to open up something that they didn’t know. You know most things. And a good therapist and one that you feel connected to will follow your pacing. It won’t have to be their pacing. And if they do that, then that’s not appropriate for you.”
— Dr. Cohen
What could I expect if I tried cognitive behavioral therapy (CBT) for my depression?
“One of the main interventions that I do as a cognitive behavioral therapist for depression is something called behavioral activation. We know that getting your body to move, doing pleasurable events, and exercising can help your brain in a way. I really start pretty early on actively engaging people in changing their behavior. That’s the theme of CBT.
“We know that social support is so important with depression. Depression isolates you so you don’t want to hang out with friends and you start slowly not connecting to people. I have patients connect to one or two friends they can just text or call and be in quick contact with that aren’t going to ask them a million questions about where they’ve been.
“It’s very difficult for a depressed patient to tell you what they did with their day. So we keep track of their daily activities with daily activity records. If somebody has been sleeping until 3 p.m., then we can set up a routine where they wake up 8 a.m. Or if they’re not exercising, we put exercise in.
“Then there’s ‘pleasurable events.’ Everything from taking a bath to getting a five-minute massage at the manicurist to calling a friend to listen to some music to go to a comedy show. And then I have them come up with other things and I assign them. So I’d tell them, ‘I want you to do two pleasurable events this week.’
“I always do psychoeducation. I explain about depression. I explain why they’re feeling what they’re feeling so that there’s a context to it. Then they can start noticing when they’re feeling potentially a little bit different during the day versus more depressed.
“Then we’ll start getting into cognitions, which is how we think and the depressive ways we think. For example, there’s black-and-white thinking, there’s catastrophizing, assuming the worst is going to happen, only seeing the negative. We start talking about these ‘cognitive errors’—this tendency to think in this way when you’re depressed. We have people notice when they’re doing it and then we work on challenging those thoughts.”
— Dr. Cohen
What can I do to manage depression on my own?
“There’s research [‘The Benefits of Exercise for the Clinically Depressed’] that shows that three days of 30 minutes of exercise with a higher heart rate is almost comparable to medication. Exercise is so important. So movement, movement, movement. Avoid staying in one place all the time. Even if that means going downstairs and walking round the block once. If you’re not ready yet to do any sort of exercise, you must move.
“Make sure to have some contact with somebody every day. Even if that means the person at the bodega while you’re getting a coffee, or your mailman. Just to have contact and conversation with at least one person. And the other hugely important thing I have found in my practice is either having your own pet or spending time with pets—volunteering at a shelter, walking a dog. Spending time with a pet can be very, very soothing.”
— Dr. Cohen
What about mindfulness and meditation?
“Mindfulness and meditation is a great daily habit to do. It is definitely not going to get you out of a depression. It’s too passive. I usually prescribe meditation and mindfulness more for long-term health and for clients who are anxious, whose thoughts are constantly berating them.”
— Dr. Cohen
How can medication help depression? How do I know if medication is right for me?
“The most common antidepressants are selective serotonin reuptake inhibitors (SSRIs). A lot of antidepressant medications also work for anxiety. And it’s not an exact science at all. The biggest thing about SSRIs that I hear is the sexual side effects. You’re not depressed, but you’re not having sex, so that’s an issue for people. If you think you need an antidepressant, you can go to a psychiatrist, who is somebody who has training specifically in this class of medications. You can also see a psychiatric nurse practitioner. Some people get prescribed from their primary care doctors. I really think you want to go to someone who really knows all about these medications, so I always recommend someone who has a psychiatric background.
“In my practice, I suggest trying medication when depression seems to be getting in the way of treatment, of therapy. Very often, therapy is engaging and it also can be difficult. You have to talk about some difficult feelings and in my experience, the more depressed you are, the more resistant or avoidant you are of those feelings and also, less able to connect in them because of the numbness or dullness [effects of depression]. In order for some people to really be productive in therapy or to use therapy appropriately, they need to be on some medication.
“My suggestion is to find a therapist who isn’t too strident one way or the other when it comes to medication. You want a therapist who’s open to looking at your individual case as an individual case—being open to being on your team, to help you figure it out together, given their expertise and what would be the best option for you. We have a lot of strategies for depression that are different. It really depends on the individual person, so you want a therapist who can really tailor it to you.”
— Dr. Cohen
Are there things I should avoid if I am clinically depressed?
“If you’re depressed, avoid drinking. Alcohol is a depressant. It doesn’t make us feel any better. It might make you feel better for the first four minutes and then you feel so much worse and you feel so much worse the next day. I would avoid drugs as well. Certainly, a lot of people when they’re depressed smoke weed. It kind of matches, ‘I’m feeling down anyways, so I might as well be stoned and chilled.’ But it just adds more avoidance to actually dealing with your problem.”
— Dr. Cohen
I’m worried I may hurt myself. What should I do?
“If you’re having any thoughts about suicidality, reach out to somebody. Tell a friend. And if they don’t take it seriously, call another friend. However, if you feel—and you will know this, you will trust your intuition—if you feel unsafe, if you feel like you might not make it through tonight or tomorrow, you need to go to the emergency room. Usually, just the act of acknowledging that it’s that serious should shift you. But take it seriously because your mind when you’re depressed is confused and not able to focus. And sometimes for some people, they become impulsive.
“There are different levels [of risk]. Low is ‘I wonder what it would be like if I were dead.’ Medium is ‘I think my life would be a lot better if I wasn’t around. I seriously think that’s an option for me.’ High is that you have a plan. You know how you would do it. And super at-risk is you have the things you need. You have a plan, you’ve written a note.
“The thing that seems to keep people alive the most is thinking about the impact that their suicide would have on other people. Often I ask, ‘What would happen if you killed yourself?’”
— Dr. Cohen
What should I do if a loved one has depression?
“I have written a piece for my website that addresses this. Here’s an excerpt:
“Asking someone who is depressed how they are doing can be a gift to them as it shows them they matter to other people. When depressed/anxious, our views of the world are internal, global, and stable, meaning we think everything is terrible, our fault, and unchanging. Therefore, providing friends with small examples of the opposite can help a lot. For example, when a friend complains about an experience where they think they failed, it’s helpful to say something along the lines of: ‘It is hard to get it right every time. I remember that time you just nailed it when we were stuck in that airport in Madrid and handled [the] situation like a pro.’ By giving examples of successes you help your friend recall and feel what it was like to be in a different state of mind than they are in right now. While you can never be a therapist to your friend, this intervention can help them shift their perspective, which is the core of cognitive-behavioral therapy.”
What should I do if I think a loved one is suicidal?
“For friends of people who are depressed, ask them. Talk about it normally. If you say, ‘Have you thought about killing yourself?’ and they haven’t, they’ll say no. It’s not like your saying that is now making them want to kill themselves. People are afraid to ask because they think they’re going to plant it in their head, but you’re not going to do that. And if they have thought about it, they will be happy to be able to talk to somebody about it because they’ve been holding onto it themselves the whole time. Don’t be afraid to ask.
“Many people think, ‘Maybe it’s not worth living.’ Many people think that. That’s so not uncommon that you can share that with people if you’re feeling that way.”
— Dr. Cohen
I’m ashamed to talk about the fact that I’m depressed. Should I be embarrassed that I can’t get over my feelings?
“It’s important for people to understand that when you’re feeling depressed, everything is going to feel pretty shameful. And you’re going to want to avoid most things. We teach people with depression and with obsessive-compulsive order (OCD) too, ‘That’s the depression.’ Name it as an outside piece, so you realize it’s not you. You have a disease. If you had diabetes, you’re not going to say to yourself, ‘Damn, why can’t I get more insulin? I’m so ashamed I don’t have more insulin.’ No. It’s a disease that you are struggling with and it is not your fault.
“If you talk to anybody about being depressed or having experienced depression, you’re going to hear a story about them or somebody very close to them who has depression. It’s a very high amount of people who have depression. Don’t be ashamed. Be clear that, ‘It’s part of me—it’s not all of me and I don’t have to be afraid of it anymore.’
“Often people come into my office and they’ll say, ‘I’m so sorry I’m crying’ or ‘I’m so sorry I’m being so negative.’ This is where you’re supposed to be able to feel those things. Feelings are okay. We live in a culture now where we’re running and running away from pain. Suffering is part of life. So the other piece of not being so ashamed of it is just accepting that it’s part of life for some people. And just because I’m not depressed right now does not mean I’m not going to go through a period of time when I’m depressed.”
Does depression ever go away?
“Yes. Depression is cyclical, so it can come back. If you’re on medication, it’s less likely to be cyclical. But when you learn CBT, the behavioral things, the cognitive challenges, you do those whenever you need. So you have the tools in your toolbox for when you’re feeling depressed. The depressive episodes might come back after treatment, but now you’ll know what to do. Sometimes you might be like, ‘I don’t want to do it.’ But you’ll never be in that place anymore where you don’t know what to do.
“I always say to people when they’re worried when we’re finishing up treatment, ‘You can teach a baby or a kid to walk. And it’s not like they don’t know how to crawl anymore. So sometimes they might crawl, but they’ll never forget how to walk.’ Sometimes you might crawl, sometimes you might not use your skills, but you know that they’re there.”
This interview has been edited and condensed.
If you or someone you care about is struggling and experiencing suicidal thoughts, you can call the National Suicide Prevention Lifeline at 1-800-273-8255 to speak with someone who can help. You can also chat with a counselor online here. All services are free and available 24/7.
