Is Minor Depression Minor?

Someone is dogged by a bad mood that they just can’t shake for a month or two.

Is it a big deal?

Isn’t some suffering expected in this universe? If someone is distressed and impaired by low grade depressive symptoms, how seriously should we take their complaints? Scholars like Jerome Wakefield and Allan Horwitz are concerned that our diagnostic system has transformed normal sorrow into a psychiatric disorder. By taking minor depression seriously, are we paying homage to the worried well?

So far the fields of psychology and psychiatry have largely overlooked minor depression. The amount we know about it is dwarfed by what we know about major depression.

Here are four reasons why you should care about minor depression.

1. Minor depression is persistent. In 2001, Mark Hegel and his colleagues studied patients in New Hampshire who went to their primary care doctor. On the doctor’s visit, they filled out a depression screener – a standardized questionnaire about common symptoms of depression. Many patients reported on the screener that they just weren’t feeling up to snuff—complaints of a low mood, vague aches and pain, problems concentrating. Some of these patients had minor depression, which involves persistent problems with a sustained low mood without the full complement of major depression symptoms. In primary care settings, such patients are encountered more often than are patients with major depression. Historically, such less affected patients often receive a period of “watchful waiting.” Watchful waiting simply means that they would be watched carefully by their physician for a time, with the optimistic assumption that most would likely get better over a period of weeks, but if they got worse, a traditional treatment for depression, like antidepressants, could be initiated. Hegel wondered if this assumption was warranted. What would happen if a group of these patients were simply followed over one month of watchful waiting? Would most get better on their own?

Much to Hegel’s surprise, only about 1 in 10 of these patients with minor depression got better in a month’s time. Nearly everyone else remained stuck in their low mood.

Epidemiological studies take Hegel’s finding one step further. Judd and his colleagues in a representative sample of the US population found that when you reevaluate people who are bumping along with a minor depression a year later, nearly 3 in 4, or 72%, will be bothered by one or more symptoms of depression.

2. Minor depression is prevalent. The persistence of minor depression helps explain why low grade depression symptoms are so prevalent in the population. More than one fifth of the population, 22 percent, suffers from at least one bothersome symptom of depression. In fact, people who have shallow depression(forms of depression that fall short of the criteria for major depression) outnumber people with deep depression 7 to 1.

3. Minor depression causes major problems. There is growing evidence that the term minor depression is something of a misnomer; it is not minor in its consequences. Individuals with minor depression may use outpatient services and miss work almost as frequently as individuals with major depression. Overall, the economic impact of minor depression is comparable to that of major depression, in part because so many more people are affected by minor depression.

4. Minor depression often escalates to major depression. The final reason you should care about minor depression is that it oftentimes does not stay minor. Minor depression has been estimated to quintuple the future risk for developing a deep major depression. Indeed, if you wonder why we have a growing epidemic of major depression, look no further than the immense pool of people with shallow and persistent low-grade depression. Thus, figuring out how and when to intervene when a person can’t shake a low grade depression is not about cosseting the worried well, it’s about denying the next wave of recruits to the army of major depression.

By Jonathan Rottenberg, Ph.D.

The Storm Rolls In

There are many myths and misconceptions about clinical depression.  One of the most tiresome is that depression is just being down in the dumps – in my experience, it’s more like being down in the abyss.  Or, that depression is just everyday sadness. Who doesn’t get sad, after all, in today’s crazy world?

But depression isn’t normal sadness – not by a long shot. Everyday sadness – which is part of the human experience for everyone bar none — is usually a reaction to some sort of loss whether in real-time (you just lost your job) or in your mind (you have a sad memory).  After some period of time, our ability to adapt kicks in and our emotional world levels off; we regain a sense of emotional balance and are ready to face life challenges.

In contrast, clinical depression is persistent sadness (according to experts, something that last two weeks or more – see a list of other symptoms from the DSM- IV as laid by clicking the link above).  This sadness does not go away.  We do not adapt. We do not return to an emotional balance without some sort of treatment — whether it’s therapy, medication, life style changes (e.g. a committed exercise regimen) or some combination of all three.

Many folks with depression may also have an absence of the normal range of emotion – particularly the ability to experience joy. There is a flat affect – an emotionally deadening; tears are replaced by simply torment. Our emotional range, if you will, our palette of colorful emotions, is reduced to variations of grey or black.  Purples, greens and yellows are simply unable to bloom in depression’s arid soil.

The predominant feeling that all depression sufferers endure, if you could call it a feeling, is unadulterated pain; a sense of darkness that sets up residence in the core of our humanity like a burned out sun that has lost its sense of heat and light.

Some people recover from depression and go into complete remission. For many that fall into this group, their depression is contained by medication, therapy, life style changes and/or some combination of all of these.  Depression does not return, thank God.

Others – in my experience many – do not per se recover.  They have periods of recovery and episodes of relapse. Or, their depression goes from being Major depression (a truly crippling condition where daily functioning is all but impossible) to Dysthymia (a milder, but more chronic form of depression). The biggest difference between the two is that Dysthymia does not usually incapacitate someone and thoughts of suicide are absent.

Stress can trigger the mercenaries of depression to return during a relapse and assault our mind’s garrisons – – a big problems if you’re a lawyer.  Too much stress, too many triggers and a lawyer who had been doing pretty well finds herself or himself falling into the basement of despair.  This underscores the importance of learning about the patterns of depression in our lives so as to head it off at the pass.

It’s as if each person’s depression (while sharing some common features – hence the DSM IV) has its own personality, like the classic children’s book Where the Wild Things Are.  We must learn read the habits of our depressions because we will then be able to recognize the signs of the trouble brewing inside our heads.

Like a storm seen in the distance from the shore, those who’ve been through a depression can sense the barometric pressure dropping and see the threatening clouds approaching. We may not tell others of this sense of foreboding because we don’t want to concern others, feel that they wouldn’t understand or conclude that they can’t do anything to help anyway.

Other signs begin to appear as the storm moves closer to shore: we don’t have the energy to return calls at the office (our voicemail box becomes digital chunks of impatient clients or opposing counsel calling back for the third time), a fragmentation of our ability to think and concentrate and a strong desire to isolate ourselves and wait – for God knows how long – for the storm to pass.

Just as storms form because of a combination of climatic condition, so too does depression.

For law students, their personality types (often neurotic, perfectionist and overachieving), run head on into the pessimistic thinking style they learn in law school – the buzz saw of learning to “think like a lawyer.”  This pessimistic style, finds trouble everywhere it looks.  It may make us good lawyers, but often unhappy – and depressed – human beings.

For practicing lawyers, the qualities they took into and learned from law school meet head on with the extraordinary demands of a modern law practice.  We’ve come to name those who grew up and fought in World War II “The Greatest Generation.” Perhaps today’s lawyers might be thought of as “The Driven Generation.” Law has become less of a profession and more of a business. 

For a lawyer who has goes through a relapse of depression, it’s often befuddling to them why they’re they are going through all this shit again. But regardless of the reason, there you are in the thick of it; the vaporous stink of depression has fallen on you like used up coffee grounds.  It seems, most assuredly, unfair.  Yet, there it is.

Here are some thoughts about preventing relapse and how to keep you feeling well:

  • Learn about how your depression expresses itself.  When you start to experience the early warning signs of a depression, talk about with a professional.  Read  5 Depression Relapse Triggers to Watch For which should give you some further signs to watch for.
  • Watch your thoughts.  In myself, I can see a shift from a relatively optimistic outlook to a pessimistic one.  I am quicker to judge others and assume the worst about them and their behavior – as well as myself.  When not in this space, I am likely to be more forgiving and – I am sure my wife would agree – easier to hang out with! Read, Therapy Better Than Antidepressants at Heading Off New Bout Triggered by Sadness.
  • People who relapse are often people who stop taking their medication.  They do so because they’ve been taking it for awhile, feel better and decide they just don’t want to take it anymore.  This can often have disastrous consequences: a return of depression or even suicide.  Beware of this and carefully plan out with a professional how to taper off medication if that’s where you would like to go.  Read, What is Depression Relapse and Can It Happen to Me?

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