We all feel stressed, irritable, exhausted and low at times. This is completely normal. For those of us who suffer from depression, however, what starts as an ordinary bout of low mood can spiral into a full-blown depressive episode.

What does depression look like?

To the outside world, Bena has her life under control. She has a job, a few good friends and does things she enjoys most weekends. If you asked any of Bena’s friends and colleagues if she was happy, they would all say “yes” without hesitation. Bena, however, has a secret, one she has been hiding for many years. Although she presents a face of contentment and competence to the world, behind the mask she suffers from depression and has done since her late teens. Too embarrassed to admit it, she tells her employers, family and friends that she suffers from migraines to explain her absences from work.

Shekkar lost his job a few months ago and can’t find another one. The sudden loss of income is causing tension with his wife, who is now the sole breadwinner. He feels a crushing sense that he has become less – less useful, less respected and less helpful to his family. Although he has been searching for work, each morning he finds it harder and harder to get out of bed, and some days he doesn’t even manage that. The fatigue can be overwhelming at times and Shekkar has begun to experience sharp pains in his chest. He is starting to wonder if his family would be better off without him dragging them down.

Rachel is fifteen years old. Her mother died in a car accident when she was twelve and it hurts so much that she never got the chance to say good-bye. Unable to talk about her grief with her father, she feels even more alone after he remarried last month. Everyone else seems to have moved on, but Rachel feels stuck and alone. Her grades have begun to suffer and she rarely goes out with her friends anymore. There have been times when she has been tempted to cut herself to try to ease the pain, and it is getting harder and harder to resist.

Bena, Shekkar and Rachel all show signs of depression, but experience it quite differently. Although there are stereotypes about what depression looks like, it can take many forms. Because of this, it can be difficult for sufferers and those around them to recognise the signs.

What is depression?

We all feel stressed, irritable, exhausted and low at times. This is completely normal. Usually, these feelings are a reaction to something happening in our lives and we start to feel better once the situation has passed. For those of us who suffer from depression, however, what starts as an ordinary bout of low mood can spiral into a full-blown depressive episode that gets worse over time.

Depression is a serious medical condition whose effects can be totally debilitating. It can stop us from being able to function. Like Bena, we can find it hard to get out of bed, and may stop going out at all. Our relationships and work can suffer, and loved ones, carers, colleagues and friends may find it difficult to understand and cope with our behaviours and moods.

The stigma and misunderstanding about depression make the condition even more problematic, and we may feel they have to hide our condition. We may also feel a deep sense of shame that we can’t just “get over it” or “cheer up” and that we are “weak” and “useless.”

Facts about depression:

  • Depression can happen to anyone of any age, gender, nationality, ethnicity, etc.
  • Around one in four of us will be affected at some point in our lives and some research studies have found that almost twice as many women as men suffer from depression. Some research suggests that men express depression in different ways, perhaps being more prone to abusing alcohol or drugs.
  • It is estimated that as many as 121 million people are affected by depression.
  • According to the World Health Organisation (WHO), major depression will be the world’s leading cause of disability by 2030. This is because it tends to start in late adolescence / early adulthood and can run a recurring course throughout a person’s life.

The average age for a first episode of depression is late twenties, and research has shown that at least 50 per cent of those who have experienced depression will suffer another episode. After a second or third time, the risk of further episodes skyrockets to 80 to 90 per cent. This increased risk is due to the fact that depression creates a pathway in the brain between sad mood and negative thoughts to the point where even normal everyday sadness can trigger more major negative thoughts that spiral into depression. For those of us with a history of depression, this downward spiral can happen incredibly quickly, and we can feel helpless in the face of it. On person described it this way: “It feels like being dragged towards and over Niagara Falls, it is terrifying and there is nothing I can do about it.”

Why do people get depressed?

There are many reasons why we get depressed, including suffering a traumatic experience in childhood, unemployment, family problems, bereavement, chronic stress or other life-changing events. If you have a family history of depression, you may be at higher risk, but that does not necessarily mean that someone with a family history will definitely go on to suffer depression. Certain chronic illnesses have been linked to depression including heart disease, back pain (and other long-term pain) and cancer. Sometimes there is no obvious reason at all why we get depressed.

What are the signs of depression?

Although we tend to think that sadness is the first warning bell of depression, we might be more aware of certain other feelings – such as apathy, anger, hopelessness – or changes in behavior, such as increased recklessness. Aches and pains in our body may be the first symptoms we complain about. The list below outlines the most common feelings, thoughts, behaviours and physical symptoms of depression.

What you might be feeling:

  • Sadness that doesn’t go away
  • Loss of self-confidence and self-esteem
  • Not being able to enjoy things that are usually pleasurable or interesting
  • Feeling anxious a lot of the time
  • Feelings of helplessness and/or hopelessness
  • Very strong feelings of guilt or worthlessness
  • Feeling irritable and/or angry more often than usual

What you might be thinking:

  • Difficulty concentrating and/or remembering things
  • Thinking about suicide and death
  • Difficulty making decisions
  • Negative and/or anxious thoughts

What you might do or say:

  • Avoiding other people, sometimes even your close friends
  • Not going out and/or avoiding doing certain things
  • Not taking care of yourself, e.g. not washing, poor hygiene
  • Sleeping problems such as difficulties falling asleep or waking up much earlier than usual
  • Finding it hard to function at work/college/school
  • Acting irritable and/or anxious
  • Self-harm

Physical symptoms:

  • Tiredness and loss of energy
  • Loss of appetite or increased appetite
  • Losing or gaining a lot of weight
  • Loss of sex drive and/or sexual problems
  • Physical aches and pains
  • Body seems sluggish and reacts to things slowly
  • Body is agitated and can’t sit still

Treatment Options for Depression

The good news is that depression is treatable. If you experience four or more of the symptoms above for most of the day for over two weeks, then you should seek help from your GP. Your GP will make an assessment and discuss possible treatment options, which may include:

  1. Antidepressants. Many people are prescribed antidepressants, finding it helpful and many will then stay on a maintenance dose for years. This can work well for some, but others experience unpleasant side effects. Some of us may also dislike the idea of taking a drug long-term and would prefer a treatment that looks at the underlying cause of the depression itself.
  2. Self-help treatments. Self-help treatment might involve reading books and listening to CDs about depression that may increase your understanding of this condition and give exercises for you to follow. Because self-help treatments rely so much on your own initiative, it can be helpful to have the support of a family member or friend to encourage you. Having reasonable and clear goals can also keep you motivated.
  3. Cognitive-Behavioural Therapy (CBT). CBT, one of the best-known evidenced-based psychological treatments, is used to treat a variety of mental and physical health problems, including depression. The idea behind CBT is that our thoughts and behaviours have a big impact on how we feel; if we can change our thoughts and behaviours, we can then change our feelings. Generally, people attend around 6-20 sessions under the guidance of an accredited CBT therapist. For example, when we are depressed, our negative thoughts tend to make us view situations in a negative light. Situations might seem worse than they really are, leading us to feel badly and do things that aren’t helpful, which can make the original situation even worse. CBT treatment encourages us to stand back and assess at our patterns of thinking and acting so that we can figure out if we’re being reasonable and accurate. If we see that we’ve been excessively negative, we can then learn new ways to adjust our thinking and behaviour.

  1. Interpersonal Therapy (IPT). IPT is a structured therapy for people with moderate to severe depression. It generally involves having 6-20 sessions plus maintenance treatment. The idea behind IPT, in relation to depression, is that our depressed mood is a response to difficulties in our everyday interactions with others, and that our depressed mood can also affect the quality of our interactions. If we can improve our relationships with others, however, then our psychological mood will improve. For example, a depressed person might withdraw from friends without explanation. The friends may in turn feel rejected and withdraw themselves, which then makes the depressed person feel unloved and abandoned. A vicious circle is created where everyone feels badly. IPT works to improve our relationships by focusing on: conflict; grief and loss; life changes; and difficulties in starting or keeping relationships.
  2. Physical exercise. Some studies have shown that physical exercise can help with depression, perhaps because our bodies create more feel-good endorphins when we are active. Exercising regularly not only can make us feel happier, but it can also boost our self-confidence, improve our sleep and lower the risk of major illnesses, such as heart disease, stroke and cancer. How much exercise you choose to do depends on your lifestyle, interests and physical abilities.

How Mindfulness-based Cognitive Therapy (MBCT) for Depression Can Help

Mindfulness-based cognitive therapy was developed to help people at risk for recurring depression learn the skills to stay well and to recover. Mindfulness is a mental training technique that teaches us to be aware of our thoughts, feelings, moods and bodily sensations as they are in the present moment so that we can see things as they are they are, and not as we wish them to be. When we pay attention to how we are thinking and feeling right now, we become better at spotting the build up of difficult emotions and thoughts so that we can deal with them more skilfully, instead of just reacting in ways that might not be good for us. We learn that thoughts are just thoughts. They are not facts and we can choose whether to give them power over our minds and hearts. Mindfulness practices include focusing on the breath and body as well as mindful movement and developing greater mindful attention to everyday activities. All of these approaches help us learn to recognise the feelings and patterns of thinking that cause unhappiness. In time they can even help us savour and enjoy all the things that give us pleasure and a sense of accomplishment.

Mindfulness-based Cognitive Therapy (MBCT) is an evidenced-based treatment that can help those of us with recurrent depression stay well in the long term. It is an eight-week, group-based course that meets once a week under the guidance of a trained mindfulness teacher. Although MBCT is not group therapy, most find the accepting atmosphere and support of the group very helpful. A referral from your doctor is generally needed to attend.

MBCT has proven to be effective and the National Institutes for Clinical Excellence (NICE) now recommends it as a treatment of choice for people with recurrent depression. In fact, studies have shown that for those of us with a history of depression, MBCT is as effective as staying on a maintenance dose of antidepressants, but without the side effects of medication.

So how does it work? MBCT combines Cognitive-Behavioural Therapy with mindfulness techniques like meditation, breathing exercises and stretching to give us a new awareness of our feelings, thoughts and bodily sensations. With practise, MBCT can help us learn to see more clearly how our minds work and to recognise the signs of oncoming depression, such as fatigue and low mood. This early detection can help nip depression in the bud before a full-blown depressive episode takes hold.

You may find this video useful, based on a book by Mathew Johnstone:  I Had a Black Dog. His wife has also added one called Living with a Black Dog.