The True Cause Of Depression

depression

About two years ago a patient of mine, Mr. Burndt (not his real name), committed suicide.  When his wife, who was also my patient, told me the news at one of her visits, I was shocked.  Fully aware that 40% of older patients who are suicidal visit their primary care doctors within one week of killing themselves, I found myself wondering over and over how I’d missed recognizing the severity of his distress.  I’d known he’d been suffering from depression but had thought it mild.

But even more shocking than the news of his suicide was the reason his wife gave for it:  six months earlier, he’d been involved in a car accident and had inadvertently killed a pedestrian.  In the end, he simply couldn’t live with the guilt.

WHAT IS DEPRESSION?

The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) classifies depression into the following types (there are even more, but these cover the basics):

  1. Dysthymia.  In essence, having a depressed mood on most days for at least two years.
  2. Major Depressive Disorder.  In addition to feeling “down” as in dysthymia, other characteristics may include excessive feelings of guilt and suicidal ideation, as well as various physical symptoms like loss of hunger and fatigue.  It can be mild, moderate, or severe.
  3. Adjustment Disorder with Depressed Mood.  This is grief due to a loss of some kind (which itself can be classified as normal or complicated).
  4. Depression NOS (not otherwise specified).  Includes things like premenstrual depression and seasonal depression (SAD).
  5. Secondary depression.  Depression due to an underlying medical disorder like Cushing’s disease or hypothyroidism.

Though not in DSM-IV, some practitioners further classify depression into two broad types:

  • Endogenous (or chemical) depression to denote depression that arises without an obvious identifiable cause, thought to reflect some kind of “chemical imbalance” in the brain.
  • Exogenous (or external) depression which is thought to arise from a specific, identifiable external cause.

Given this confusing and non-parallel classification scheme it’s astonishing doctors don’t become depressed themselves as they try to figure out into which bucket their patient’s depression fits!

How can we make sense of all this and, more importantly, understand the real cause of depression in order to augment the effectiveness of currently available therapies?

MIND VS. BRAIN

First, we need to recognize the distinction between chemical and external depression is becoming outdated.  Many neuroscientists have suggested that the mind arises from, and is actually caused by, the physical brain, meaning chemical and electrical reactions somehow give rise to thoughts and emotions.  Evidence in support of this theory can be found in numerous studies that show altering brain chemistry with anti-depressant drugs (chemicals) can make depressed people feel better emotionally.  The same is true for anxiolytics (like Valium) and their effect on anxiety.

But recently, with the advent of functional MRI scans (fMRI), we now have proof the opposite is equally true, that changes in thinking cause significant, measurable changes in brain chemistry and functioning.  In one study, patients suffering from spider phobia underwent fMRI scanning before and after receiving cognitive behavioral therapy aimed at eliminating their fear of spiders.  Scans were then compared to normal subjects without spider phobia.  Results showed that brain function in patients with spider phobia before receiving cognitive behavioral therapy were abnormal compared to subjects without spider phobia but then changed to match normal brain patterns after cognitive behavioral therapy.  This may represent the best evidence to date that changes made at the mind level are able to functionally “rewire” the brain, and that the brain and the mind are more mutually influential than we’d previously thought.  It certainly supports the Buddhist view that brain and mind are in fact only two sides of the same coin, or different ways of viewing the same single thing.

DEPRESSION ALWAYS HAS A CAUSE

Where, then, does the true cause of depression lie?  In the context of the critically important caveat that clinical depression is almost certainly more than one disease with more than one proximate cause, I would hypothesize that in most cases depression arises at its core from a belief that we’re powerless to solve our problems.

This is clearly true with people who know why they’re depressed:  invariably, once they figure out how to solve their particular problem, their depression lifts.  But I would also argue this likely holds true for people who are depressed for no reason they know as well.  Why?  Because thoughts can trigger feelings that remain stirred up long after the thoughts themselves have been forgotten.  Some studies have suggested people think upwards of 12,000 thoughts per day.  How could we ever remember them all?  Yet a fleeting thought we might have had this morning about the possibility of losing our job can and often does leave an emotional residue that lasts hours, days, weeks, or even longer.  I would argue, therefore, any depression that appears to be “chemical” may in fact be caused by a thought that simply isn’t remembered—a thought about a problem we don’t believe we can solve.  (I should note, on the other hand, that many of my psychiatrist friends tell me they have depressed patients who tell them their lives are “just fine” but that they’re depressed anyway.  To tell if such people are depressed because of unrecognized cognitive distress, as I just suggested, or because of some non-cognitive abnormality is extremely difficult, if not impossible.  If such patients never successfully identify a cognitive distortion as the true cause of their depression does that mean it never existed or they just never found it?)

Further, sometimes what appears to be a “chemical” depression is caused by a thought that isn’t directly or consciously recognized.  These thoughts are often about problems that seem so unbearably awful and unsolvable we literally don’t want (and often refuse) to think about them (such as our becoming jobless or the prospect of our own death).

Finally, I believe the commonly accepted idea that some forms of depression like depression NOS and secondary depression (#4 and #5 above) are caused by chemical or hormonal abnormalities may overstate the case.  I wonder instead about an alternative explanation, that these forms of depression have a chemical or hormonal influence—reducing our ability to believe we can solve our problems but not entirely eliminating it.  At first glance this might not appear to be a significant distinction given how incredibly difficult it is to believe in our ability to solve problems, for example, when experiencing premenstrual syndrome.  But knowing intellectually we can win even if we’re having a hard time believing it can help to sustain the most valuable thing depression tends to reduce:  hope.

HOW CAN WE HELP OURSELVES?

None of this is by any means to say we can simply decide to believe we can solve a particular problem when no solution is obvious or forthcoming.  Changing any belief, whether consciously recognized or not, is one of the hardest things to do.  But armed with a clearer understanding of the true cause of depression we can consider the following steps to help ourselves:

  1. Find a way to raise your life-condition.  Your inner life state has more to do with your ability to believe you can solve your problems than anything that may be actually going on in your life.  If your thoughts are swirling in despair, take action to break free of them and attain a fresh perspective.  Become immersed in a great book that moves you or watch a movie that transports you.  Exercise.  Go where it’s warm.  Chant Nam-myoho-renge-kyo.  In short, do what you know from experience bounces your thinking to a more optimistic place.
  2. Identify the problem or problems you don’t think you can solve.  It’s amazing how often you don’t know why you’re depressed and how helpful it can be to figure it out.  Making a list of everything that’s bothering you—a sort of stream-of-consciousness rant on paper—can be a fantastically helpful exercise.  Or if you do know why you’re depressed, recognizing the cause isn’t that you have a problem per se but rather that you have a problem you don’t believe you can solve can be remarkably empowering.  Also, sometimes we become depressed not because we have one problem we believe we can’t solve but because we have multiple problems we believe we can’t solve.  Handling challenges can be likened to balancing a “plate” of a certain size:  if we pile too many problems onto it, not only do we risk having it topple over, we often find ourselves wanting to pitch the whole thing on purpose.  When this is the case, allow yourself to only worry about and focus on solving one problem at a time.
  3. Identify the reason a problem seems unsolvable.  As I pointed out in a previous post, Changing Poison Into Medicine, many things erroneously cause us to conclude we’re deadlocked, chief among them our inability to identify a solution to our problem right now.
  4. Recognize that your thoughts are profoundly influenced by your mood.  Once depression has established itself, it takes on an insidious life of it’s own, further diminishing your belief in your ability to solve problems, your ability to plan, and your ability to have hope for the future.  In this way the cause of any depression always reinforces itself.
  5. Remember that your depressed self is not your true self.  Whatever life-condition you find yourself in at any one moment always feels like the only life-condition you’ve ever had or will have.  But your life-condition can and often does change literally from moment to moment.
  6. Understand that anti-depressants only treat the symptoms of depression.  None of the foregoing has been intended as a denial that anti-depressant medication plays a critical role in the treatment of depression.  In the right patient, anti-depressants reduce the symptoms of suffering exceptionally well and can be literally life-saving.  Research is especially clear that combining anti-depressant medication with cognitive therapy is more effective than either alone.  But anti-depressants can’t make anyone actually happy because happiness isn’t merely the absence of suffering.  The best approach, in my view, is to treat the symptoms of depression with anti-depressants (or cognitive therapy or even electroconvulsive therapy) when symptoms are severe enough to warrant it while at the same time attempting to address the underlying cause of the depression itself.

I fully recognize that as a means to battle depression—especially a deep, all-consuming depression—these suggestions are inadequate.  My point in making them, however, is to emphasize that the single most effective means to resolve a depression is to find a way to tap into our immense power to solve problems.

In a sense, we’re all on a journey to find just such a way.  For me, the practice of Buddhism has been a consistently effective means by which to win over obstacles I didn’t believe I could, a tool that has enabled me to manifest wisdom, courage, and most importantly concrete solutions I don’t believe I would have stumbled upon had I not been practicing.  If you have a different means that your experience has demonstrated works, stick with it.  If not, spur yourself on to explore other paths until you find one that proves it has real power.

In retrospect, I wish I’d suggested to Mr. Burdnt that he think about his guilt over the death of the pedestrian he caused as a problem to be solved—and more importantly as a problem that could be solved.  Perhaps had I also begun him on an anti-depressant medication to stave off what were obviously strong suicidal thoughts, he might have had time to work through his guilt.  Perhaps he could have shaken loose from its grip in time to forgive himself, and his depression might have lifted.  But I’ll never know.  And that’s a problem I have to solve for myself.

NEXT WEEKOvercoming The Fear Of Death

My new book The Undefeated Mind: On the Science of Constructing an Indestructible Self will be published on November 6. Please read the sample chapter and visit Amazon or Barnes & Noble to pre-order your copy today!

105 comments to The True Cause Of Depression

  • Norah

    Alex: a very profound discussion of what infects so many of us in these modern days. A lot of people suffer from mild depression, because their life seems to fall short of their expectations. Those patients with more severe underlying causes, such as bipolar (which my son suffers from) need professional help to get them able to recognize problems. An excellent and thoughtful text. Thank you once again.

  • A wonderful and thought-provoking discussion on depression. There are so many facets to depression, but one major aspect that is not properly addressed is modern human’s propensity for problems breathing while sleeping. This is due to our jaws being too crowded from a major change in our diets, and as a consequence, our airways are more and more compromised. In effect, we can’t stay in deep sleep due to our tongues falling back and obstructing our breathing due to muscle relaxation. Lack of consistent deep sleep can lead to lack of energy and motivation, magnifying external or cognitive triggers. This is why most people with depression or anxiety prefer to sleep only on their sides or stomachs, in order to partially compensate for this airway problem. Later on in life, many go on to develop obstructive sleep apnea and it’s complications such as heart disease.

    Steven Y. Park, MD
    http://www.doctorstevenpark.com

    Steven: Thanks for your thoughtful comments about the contribution poor sleep often makes to depression. I find in my practice too that sometimes patients can’t tell the difference between extreme fatigue and depression itself (!) and I certainly see how often chronic fatigue can exacerbate or even cause depression. I am a huge proponent of people getting adequate sleep and, I imagine, like you diagnose sleep apnea quite frequently.

    Alex

  • Ashley Osment

    This is a timely conversation for me. I am 45, have Stage IV ovarian cancer, and we have a 12-year old daughter. Nearly two years since my diagnosis, while going from Stage I to Stage IV upon the discovery of distant metastases, I’m still healthy and central to my family’s health and welfare. Still, depression is a constant shadow. Between the discomfort of cancer treatment and my poor prognosis, I have lost that “I love my life!” feeling that I used to have. I don’t love my life, now. I despair for it. It would be amazing, wouldn’t it, if I could regain such a feeling even under these circumstances?

    Ashley: I can hardly imagine how difficult it must be for you to maintain a life-condition in which you feel hopeful and joyful. I would think everywhere your thoughts go end in the same bad place. I have a close friend, even younger than you, recently diagnosed with breast cancer who has a sixteen month old son. Even though her prognosis is excellent, she’s lived in intermittent terror of leaving her son without his mother. It’s been a real ordeal.

    In wracking my mind to find something encouraging, I find myself thinking two things. First, I really do believe it is possible to regain the feeling of loving your life even in your circumstances. I don’t believe you can necessarily DECIDE to recapture that feeling. I think you need a process that can actually raise your life-condition based on your discovering new ways to think about your situation that have actual validity for you. Whether you’re religious or not, I would encourage you to check out the link to the SGI on my “About” page. If you’re so inclined, Buddhism may have something to offer you. The second thought I had was this: I’m sure your daughter is watching you go through your illness very intently. Whatever the final outcome, perhaps it might help you to focus your thinking more on the lessons you might be able to teach her about how to handle a situation such as yours and find comfort and even some relief from your suffering by recognizing you have a unique opportunity to prepare her in a positive way for difficult situations that she will undoubtedly face in her life. My father once remarked to me that he hopes to be able to teach his children by his example how to face death well when his time comes. I don’t think it’s a foregone conclusion by any means that this experience will only and ultimately have to be a negative one for your daughter. The very best of luck to you and your family.

    Alex

  • Being able to sleep changed much of my life, as a lifelong insomniac, and helped stave off my mood disorder. As did medication.

    And while I’ll add that I understand and feel that meditation of any kind helps people live healthier lives (as does exercise) I do think folks should understand that it’s NOT a cure for a mood disorder.

    I know we disagree on this, Alex, but as someone who chanted hundreds of hours over the course of four or five years before solving my problem in a couple with a prescription, I also feel it’s important to point out.

    Josh: Not sure we do disagree, actually. I too think meditation and/or chanting can help people live healthier lives and that they WON’T cure a mood disorder—unless they lead to a specific breakthrough with regards to the underlying cause. It may be a breakthrough in a predisposition to feel defeated in general (very hard to achieve) or in regards to a specific problem (perhaps a little easier). I think you can meditate or chant for years or even decades and not have that breakthrough–but not having that breakthrough doesn’t mean the path you’ve chosen won’t eventually produce it. You’re quite right to point out the enormous value of medication that can resolve the symptoms of a mood disorder that interfere with your ability to function, but, as I pointed out in the post, that medication doesn’t cure the mood disorder either.

    Alex

  • Joyce

    Dr. Alex, I would like to read this website but it is very hard on the eyes to read grey on black. Can you please change it to a more normal color scheme like black on white? Thank you.

    Joyce: As several others have given me similar feedback, I offer a new theme for your reading pleasure. I hope you find it easier on the eyes!

    Alex

  • Great article Alex. You have an interesting perspective on things being a physician and a Buddhist. Given that the Buddhist believes that the challenges we face in this life are the result of our actions in previous lives (through the Law of Karma) I would be really interested in reading your thoughts on Karma and it’s relationship with illness…huge topic I know!

    Julian: Interesting idea for a post. I’ll give it some serious thought, thanks.

    Alex

  • SIA

    I find you blog interesting. I saw it on a link in a NY Times article. I also share your belief in mind as a major Cause. Do you ever read the words of the wonderfully enlightened Mystic Neville Goddard? His lectures are great. You might check him out at http://www.realneville.com/

    SIA: I haven’t read Neville Goddard. Thanks for the link. I’ll definitely check him out.

    Alex

  • chris bacon

    Having worked as a therapist in psych hospitals for 20 years, suffered my own clinical depression and being a practicing Buddhist at that time, I feel I must comment. Clinically depressed people who kill themselves do not talk about it before hand. They just do it. No one sees it coming. Psych hospitals get suicidal people who don’t really want to die; those that make suicide gestures and create lots of drama in their lives. When I was contemplating suicide as one of my options, I was chanting and seeing a psychiatrist weekly and taking medication. It took a year and several cycles of medication to get me out of the depression. Not once did I disclose to my psychiatrist that I was suicidal. So, Alex, don’t beat yourself up about not seeing it coming. Those who were with him every day didn’t see it coming, either. That is the nature of a truly suicidal person: THEY DON’T TALK ABOUT IT.

    Chris: Thanks for both the perspective and the encouragement. I completely agree suicidal people don’t talk about their plans for suicide—unless they’re ASKED directly about them. Which is why in medical school we’re all taught the critical importance of doing so. I try not to beat myself up in general, but I certainly regret not asking my patient if he was considering suicide. My own experience is that when I do ask people they almost always answer honestly. It was just a missed opportunity. It honestly never occurred to me he would be suicidal from having accidentally killed someone. I guess I’ll know better to ask next time.

    Alex

  • [...] a previous post, The True Cause Of Depression, I discussed how having multiple problems at once seems to cause more stress than having only one [...]

  • Andrea

    A year ago the elderly mother of a friend swerved into oncoming traffic, jumped the curb and killed a beautiful, gifted young woman who was a pedestrian. My friend asked me immediately if she could get a referral from my psychiatrist. He gave her one. He also told me that there is a long history of people who kill others in accidents of committing suicide whether they were at fault or not. Before car accidents were common, it happened with train conductors. One of the first psychiatrists in Buffalo, N.Y. switched from being a surgeon to psychiatry after he killed a pedestrian and made a suicide attempt. Since you are a primary care physician and not all psychiatrists know this, give yourself a break.

    Andrea: Thanks for the encouragement. And I didn’t know that it was a recognized phenomenon that people who kill others in accidents are at risk for committing suicide (though it certainly makes sense).

    Alex

  • Paula Bloom

    Saw your comment about depression on Sanjay Gupta’s blog yesterday. I like the point you made and enjoyed the above article!

    Paula: I’m glad you did. Thanks so much for stopping by.

    Alex

  • Susan

    I have been cycling downward lately precisely because I feel powerless. Your post felt like you were talking to me directly. Thank you for the insight. I will try to see all that is within my control, instead of what is not. It will be a process, but I already feel more hopeful. You should do the same—think of all the people you are helping, not the one who got away.

    Peace

  • shri kanekal

    “…it certainly supports the Buddhist view that brain and mind are in fact only two sides of the same coin, or different ways of viewing the same single thing…”

    This is the view of Hinduism as well. The yoga sutras of Patanjali not only define yoga as the “prevention of the distortion of the mind” but also indicate a path and provide a detailed prescription to achieve this.

    States of mind such as depression are a kind of “distortion” (the sanskrit word is vritti) and are to be overcome by a directed and willfull effort, i.e., performing right karma.

    It is interesting that observations such as fMRI seem to be supporting such a view.

  • Karen K.

    In a video about the life and work of William Kentridge, a contemporary South African artist who has thought long and penetratingly about apartheid, he asks: if you hit a pedestrian with your car and kill him, you’re responsible for his death–but are you guilty of it?

    This is a fascinating question, I think. What does it mean to be responsible but not guilty? Could this distinction possibly help people like Mr. Burndt? Is it easier to accept responsibility than guilt? Or are they basically the same thing?

    Karen: An intriguing question. Perhaps guilt should be distinguished as appropriate only in instances in which one is responsible for an intended negative outcome. Mr. Burndt was certainly responsible for whatever driving choices he made that led to the pedestrian’s death, but he certainly didn’t intend to kill him. Maybe if he could have made that distinction he wouldn’t have been plunged into such despair. What do other readers think?

    Alex

  • Penelope

    Alex, thank you for your comments. I find them very helpful and comforting. I’ve had a life-long battle with both anxiety and depression. While it became clear to me through cognitive therapy that the depression was connected to feelings of helplessness, just as you suggest, I found other factors as well.

    One of these turned out to be allergic reactions (determined by lab tests) to mold and also to soot that had been baked on my apartment windows by the hot sun. (I used to live in New York, which is very sooty.) As soon as the mold or soot had been cleaned up with vinegar, the whole world looked different—literally, of course, but on an emotional level as well. I felt like a different person. It was only after doing this that I realized what had been causing my misery.

    Later on, in 1995, tests of neurotransmitter levels in blood and urine showed that I had rock bottom blood levels of serotonin and catecholamines and high levels of them in urine. On my doctor’s advice I began taking L-Tryptophan, which of course is a precursor of serotonin. It helped a lot. As did taking L-Tyrosine on an empty stomach to produce dopamine. A few years ago tests indicated genetic damage that had been caused by exposure to environmental toxins. My body had lost the ability to make the enzymes needed to produce dopamine.

    I still find it helpful to take L-Tryptophan and L-Tyrosine daily. The latter eliminated a huge problem with anxiety that I had been unaware of. All of these measures, including cognitive therapy and the avoidance of toxins, have helped but i still need to take care and do the things you have suggested as well. So thank you again for your blog, which I’ve just discovered through the NY Times.

    Penelope: Thanks for such a fascinating comment. It so well illustrates the interconnectedness of the mind and brain and is a good reminder that physiological causes of depression are very real (as in pre-menstrual syndrome or hypothyroidism as well).

    Alex

  • Renske

    Hi Penelope,

    English is not my first language so I maybe don’t understand everything you’re saying, but are you writing that your serotonin levels could be MEASURED? Because my doctor (either my GP or psychiatrist, I don’t remember) was suggesting that you can’t measure it.

    That’s also one of the reasons that my psychiatrist and I haven’t decided to start with anti-depressants, because there are some clear underlying reasons to my depression-like feelings. Only I would be really pissed-off if it could partly be cured (or maybe I should write “cured”) by knowing the levels of serotonin in my blood…

    Renske: It IS possible to measure serum and urine levels of serotonin (and/or its metabolites) but no standard exists for determining what levels might be associated with depression. Further, it remains unclear that low serotonin levels actually CAUSE depression and that selective serotonin reuptake inhibitors (SSRI’s) actually improve depression specifically by increasing serotonin levels (there may be other mechanisms in play we don’t yet understand). Using serotonin levels as a way to decide whether or not to initiate treatment for depression with SSRI’s isn’t standard practice, nor is it likely to be clinically appropriate. Though Penelope reports success with her treatment, I feel it’s important to point out that the approach her physician took isn’t standard.

    Alex

  • AJ

    Speaking as someone who heads up a research group of cognitive scientists, I’m concerned with your suggestion that cognitive therapy can help everyone. It cannot. Some people can be helped by drugs where everything else fails. They are extremely fortunate at least in having some resource, and trying to go off the medication can cause very severe episodes with the possibility of suicide.

    AJ: I didn’t mean to imply I thought cognitive therapy can help everyone, so I’m glad for your comment, which gives me the opportunity to clarify the point in case others have misconstrued what I wrote. Clearly, cognitive therapy often fails to help improve many people who are depressed. I would argue when it fails, however, it does so in a specific way—by failing to identify the context in which the depressed patient feels powerless and more importantly by failing to instill in them a belief that they’re not. This would seem especially difficult a task for cognitive therapy to accomplish in the setting of a depression occuring secondary to a medical problem, like hypothyroidism, for example. It’s clear as well that some people are only helped by anti-depressants, and I fully agree that such people are incredibly fortunate that we have such effective weapons in our arsenal. I fully agree as well with your warning that going off such medications can put depressed patients at risk for suicide. I stand by my assertion, however, that no anti-depressant ever cured the cause of any person’s depression, but rather that they’re extremely good at controlling the symptoms of depression (the critical importance of which I in no way meant to diminish).

    Alex

  • RG

    Interesting theory, and it sounds good, but also sounds simplistic. Depression does feel overarching, not just a minor problem that hasn’t been solved but a sense that even if I solve this tiny problem, 20 others like it will crop up tomorrow. When I was a grad student at U of Chicago, it felt like being on an endless treadmill with various milestones, to finish the PhD, to get tenure, to achieve recognition in my field. And the problem was that I wanted the recognition and achievements but also wanted more balance in my life than I was likely to find. To say that I felt my problem unsolvable is true, but it misses the point: someone who is not depressed doesn’t get into that thought loop. I was in a division of 80 grad students, and I doubt more than 10 of them were so good that they could be confident of their career in academia; but the rest of them were okay to take it a day at a time, to do research and take breaks and see what happens. To some degree my problem was unsolvable, but to a larger degree it was just life presenting me with limited choices.

    RG: You make a good point. Ultimately, I think the true cause of depression isn’t just feeling yourself to be powerless to solve specific problems, but rather being trapped by the perspective that you can’t solve problems in general in a way that will enable you to be happy. The cause is, in effect, feeling defeated by your problems in your heart. Sometimes it may be a single problem that you feel powerless to overcome (which may not be a minor problem at all—for example, the problem of death) that then depresses your life-condition and causes you to feel you can’t solve other problems that previously you might have felt like you could. At some point the feeling of depression takes on a life of its own and colors how you feel about everything, but I maintain the original cause of that life state lies in feeling defeated by something.

    Also, to your last point, I find sometimes it’s the very conception that we have limited choices that traps us in a feeling of powerlessness. Usually, with regard to myself at least, when I consider I’m being presented with limited choices, the reality is I’m being presented with limited choices that I find acceptable. There are almost always a whole host of other choices that I won’t even consider (for whatever reasons) and not infrequently it’s one of those other choices that hides the best answer, though I refuse to accept it until I’m forced.

    Alex

  • RG

    Thanks for your reply. I’m not sure we’re finding common ground, and I’m not sure why. It feels like you’re trying to force your paradigm on my experience with depression. Another way to explain this: Anna Maravelas has a great book on conflict resolution and in it she talks about the fact that life presents us with 10,000 “heart hassles” every day. And in my experience, how I respond to these problems depends on neurochemistry not on the problems themselves. Someone cuts me off in traffic, I’m up two pounds on the scale, a waiter spills water on me—the rational part of my brain knows that these “problems” are unsolvable because they’ve happened and the resulting problem (I have to change shirts) doesn’t require problem-solving skills. Depression feels like an inability to deal with the vicissitudes of life, often a real mental slowing occurs. I’ve had a few of these periods, post-breakup, where I could sense that my ability to think was like stop-and-start traffic. It’s not so much that I had any unsolvable problems; it’s an overall coping ability that was quite simply gone. The point is that when I’m not depressed, the same problems will show up in my life and I will be able to pick from the limited choices and be comfortable with the lack of perfection, “cross that bridge”, etc. When I’m depressed, I’m not more realistic about the lack of perfection, I’m not more hopeless about my ability to cope with the consequences of that imperfection, but there is a kind of “leap of faith” that moves me from the scientific, dissect a problem, to the big-picture, trust my gut. And a depressed brain can’t make that leap of faith; it gets stuck in the endless analysis. A lot of negative issues become magnified—anger is bigger than it is normally, guilt is magnified, anxiety and second-guessing is huge. What it most resembles is that last time you got 2 hours of sleep and had to get through a normal day before you could take a nap. Nothing quite works.

    RG: I apologize if it seemed as if I were trying to force my paradigm on your experience with depression. That wasn’t my intent. And from your comment I think our views do share common ground: if I understand your point correctly, we both agree that once you’ve entered into a depressed state, it’s that state itself which denigrates your ability to respond to life’s vicissitudes as you normally would. Where I think we do differ is in our conception of what triggers a person to enter a depressed state. I don’t view neurochemistry as the ultimate cause of mental processes (eg—a depressed state) but rather a reflection of them, chemistry and thought each able to mutually influence the other. Of course, my theory that a depressed state (and its mirrored alteration in neurochemistry, whatever that may be) is ultimately triggered by the stirring up of a belief in one’s powerlessness in some significant realm or circumstance is just that—a theory (though one that’s fit my observations best). Thanks for a lively discourse.

    Alex

  • RG

    I’m genuinely trying to wrap my brain around what you’re saying, because it sounds so tempting. It sounds like you think there are two distinctly different states, a functioning brain and a depressed brain, that operate very differently where I see more of a spectrum, the way that even one sleepless night can significantly lower coping. I also think you’re confusing correlation and causation, like yo-yo dieters who blame their weight gain on dieting. Stress causes malfunction causes failure causes depression. I suspect your driver’s brain was off-kilter before he hit the pedestrian. The powerlessness is an “obvious” distraction—someone who’s depressed enough to see a doctor probably has failed something in some way.

    My depression—I’ve struggled with it for decades—is high-functioning. None of my teachers had the smallest clue that I was actively suicidal in high school. And I do see it like dieting, that I had to retrain my brain away from the thought patterns my parents had handed me, away from workaholism and perfectionism and letting minor setbacks snowball in my head. I had to learn to eat better and exercise often and get plenty of sleep. The ability for a daily run to prevent long-term depression is simply astounding. I had to see the warning signs of stress and learn how to set boundaries earlier—with people, advisors, my own life goals. Being attuned to it, I also realized that I was heavily impacted by light, and Chicago winters took a heavy toll on me. Powerlessness isn’t a theme in my depressions; if anything, there was too much power, too many choices and the sense that my life path rested on those choices.

  • Fran

    Found you via the link in Gretchen Rubin’s Happiness blog. I am glad to find your conversation with RG, as my experience leads me to agree with his spectrum description rather than the either/or view of depression. I am on meds for anxiety/depression, which was diagnosed postpartum. RG’s comment about the “leap of faith” being absent reminded me of the feeling of not being able to access states of being and perspective that I had long counted on—like pathways had been blocked. Were those pathways blocked by my anxiety? Or did the blocked pathways trigger the depression? This is an important distinction for me, because I am not convinced that there is a clear separation of cause and symptoms with regard to depression. If I understand you correctly, you say that depression is caused by the belief that I am powerless to solve my problems. If finding the correct meds restored my feelings of power (which to me felt like restored access to power), thus reducing my anxiety/depression, am I treating only the symptoms?

    I have long thought that breakthroughs in medical understanding will come from better clarity regarding cause and effect. For ex., I have seen studies that suggest that drinking too much puts a woman at higher risk for breast cancer. Is it possible that whatever makes a woman drink too much is what triggers the cancer?

    Thank you for addressing these questions. I appreciate the discourse.

    Fran: I acknowledge that, as the cause of a depressed state, belief in one’s powerlessness over something can be extremely hard to detect. And I didn’t mean to come off with RG as a Freudian who argues his patient’s refusal to believe in his explanation for his patient’s symptoms is part of the patient’s disease itself and therefore has no legitimate basis.

    I think depression is either present nor not, but manifests in varying degrees of severity. And when depression does occur, a whole series of symptoms accompany it, many of which both you and RG mentioned, depending on the depression’s severity. But I still think what triggers depression is a sense of powerlessness over something. If, for example, your significant other breaks up with you but you maintain complete belief in your ability to get him back, I don’t imagine you’d become depressed. Depression apparently connected to a medical condition is admittedly harder to fit into this model.

    What may be especially confusing about my argument that depression is caused by a belief in one’s powerlessness is that depression is also known to cause feelings of powerlessness. I view it like this: a belief that one is powerless over a particular thing is what sets off a depressed state, which, once established, leads to general feelings of powerlessness over things that one would normally feel quite capable of handling. I hope that makes my position clearer and addresses your questions.

    Alex

  • kim

    Alex, you have a wonderful blog and I count myself lucky to have found it. I’ve read many of your posts and have been struck by the wisdom and thoughtfulness in your words. You appear to ground your professional work in your Buddhist practice much as I draw on my own many years of yoga practice and experience to ground me in my profession.

    Therefore, it saddens me to read this post and find myself having to say: You don’t know what depression is. You truly don’t know what you’re talking about here. But you have constructed an all-too-familiar refrain, one that is tossed at people with serious depression with wearisome frequency by the non-depressed. Let me gently point out that elaborate speculative theories like those you have constructed above are an expression of your prejudice towards and your social disapproval of depression and people who have it. RG is trying to explain it to you, but you’ve cotton wool in your ears and are refusing to hear him/her.

    I say this as someone who developed depression some years ago as a secondary result of a serious and disabling medical condition (pulmonary). I had no history of depression before that time; it was a new (awful) world to me. All of my excellent coping skills (strong mind, strong constitution, long yoga practice) were useless against severe depression. Indeed, as RG tried to explain, the physical disease of depression disables such coping skills, just when you need them most. But this is too long a discussion. In short, I invite you to please seek out and read very recent research—the field is advancing rapidly. Search terms “major depression” and “HPA axis” for starters. For the sake of your own patients, at least.

    Chris Bacon (above) also has it right: “Clinically depressed people who kill themselves do not talk about it before hand. They just do it.”

    Kim: While I can certainly appreciate your view and acknowledge that my theory is just that—a theory, about which reasonable people can disagree—I must take issue with your statement “that elaborate speculative theories like those you have constructed above are an expression of your prejudice towards and your social disapproval of depression and people who have it.” Nothing could be farther from the truth. I, also, have struggled with a serious depression and it was awakening to the fact that I believed with all my heart I was powerless to be happy as a result of what had happened to me (a belief, I might add, I literally didn’t know I held until the moment I realized it wasn’t true) that finally brought me out of the very real life-condition of depression, which had disabled my coping skills (among many other things) as you describe it had yours. But it was the hardest, most painful thing I’ve ever done in my life to both see it and change it—and not accomplished by attempts at introspection, which I found useless.

    By stating that believing in one’s powerlessness is the true cause of depression I didn’t mean to imply breaking through that belief is easy—rather its exact opposite. I think changing one’s deeply held beliefs is literally one of the most difficult things for human beings to do. But it’s just been my observation, both of myself and others, that the stirring up of different beliefs is the inherent cause of every emotional state we experience, even as we cycle through hundreds or thousands of them a day. If you took my theory as an indictment that depression is “chosen” by the depressed and that all they need to do is just stop believing they’re powerless, as if it were a conscious choice, you’ve misunderstood my position.

    Alex

  • As someone who hails from a genetic pool full of depressed people and who has been diagnosed with many of the things you’ve written about here, I felt the need to comment. I do agree that some depression is self inflicted—that our warped way of viewing and thinking about the world is what brings us down. But I can say from self observation that not all of it depression is caused by our thoughts. There is definitely a chemical component that is not at all related to thoughts. I have days when my life is wonderful and when I think that my life is wonderful, but when I feel very flat. I used the word “flat” to describe this sensation because it has no positive or negative connotation. It’s also exactly what it feels like. There is little exuberance. Smiling and laughing feel forced. Paying attention to what other people are saying? It’s an exercise. I don’t feel like doing anything.

    There’s no out thinking it. It’s just something that is there. It’s a crummy feeling that lasts until it stops—usually after I do something that changes my brain chemistry (sleep, aerobic exercise, sex etc). Certain things will bring this state on. They include eating crappy food, alcohol of any type or amount, and fatigue.

    In calling it “flat” and knowing that it won’t last forever, it’s not so depressing to feel depressed.

    I do agree that our society is very quick to judge all depression as chemical. So many people are taking pills for their depression when they quite possibly could be out thinking it. (Note: I am not medicated and never have been). But I also think it over simplifies things to say that none of it is chemical. It’s a little of both, and if you treat both the thoughts (through CT and problem solving) and the chemical issues (through exercise, abstinence from alcohol, a healthy diet, sex, fun, and so on) you might end up with a winning combination that would help a lot of people feel a lot better.

    Alisa: Thanks for your comment. I, too, have days when my life is wonderful but I feel flat as you describe. My self-observation, however, has led me to a different conclusion than yours that some depression is due to a “chemical component that is not at all related to thoughts.” Just because you can’t identify or remember the thought that made you feel defeated or flat doesn’t mean it never existed and that your flatness is due to a chemical component. And the problem isn’t even so much with thoughts, in my view, as it is with the beliefs our thoughts stir up. If you believe, for example, you’re not lovable, many thoughts can stir that belief up throughout your day, causing you to feel flat, or worse. It’s my contention that it’s always some belief, whether consciously recognized or not, stirred up by thoughts, that thrusts us into a depressed or flat life-condition. Whether or not those beliefs arise out of faulty brain chemistry isn’t known, though it seems most logical to me that brain chemistry and thoughts/beliefs don’t cause one another but rather mirror one another—that they’re actually two different ways of looking at the same thing. I’ve attempted in this post to describe what I’ve observed as the mechanism of depression, but by no means do I think just because the true cause of depression lies in the stirring up of beliefs that lead you to feel defeated that you can simply “out think” them. Changing thoughts is easy. Changing beliefs is incredibly difficult, perhaps more difficult than the most difficult thing you can imagine doing physically. A misguided belief can be literally as hard to break through as a brick wall. Cognitive therapy, when it actually works, often seems to work by freeing us from these kinds of beliefs. Anti-depressants, on the other hand, seem to lessen the effects these beliefs have on our life-condition without actually changing them.

    In any case, interesting food for thought!

    Alex

  • I think part of the problem is that the term depression in actuality encompasses so many different conditions. It’s analogous to a “syndrome” which is nothing more than a collection of symptoms that some people seem to share. The etiology of the disease may be in fact quite different in different patients thereby altering the treatment. For some people, a sunny disposition is in the genes, for others, not so much. It’s also usually a source of great creativity. How many brilliant authors were cheery? Probably one of the best things I read on depression was Thomas Moore’s “Gift of Depression” in Care of the Soul. It completely changed my view on it.

  • Helen from Hawaii

    I’ve had depression since childhood. I am now 60 years old and have obtained four college degrees (science, medicine, and law) despite depression so severe that I am now 100% disabled.

    I’m a fighter. I moved to Hawaii to be warm. I used to chant. I learned to sail and lived on a sailboat…I did everything to pull myself out of depression…psychiatrists, CBT, every anti-depressant there is. I have achieved great honors.

    I don’t announce I am suicidal, I really try to do it. 250 Tylenol and 2 bottles of whiskey (I don’t even drink), and wasn’t found for 3 days; yet I made it out of the hospital without even liver damage. The second time I tried to decapitate myself by tying my neck to a rope and the rope to a carport and getting in a car and hitting the gas pedal. The timber of the carport gave way to termites.

    These are not “attention getting.” I want to die.

    I feel completely empty and always have, no matter what great service to mankind I have done; no matter how much powder skiing, sailing to Tahiti, or backpacking I have done, I feel completely despondent and empty.

    So now what, doctor?

    Helen: I’m so sorry to hear you’ve suffered so tremendously for so long. Unfortunately, without knowing the details of your history I couldn’t make a specific recommendation, and generalities would probably be of little help. I will correspond with you by email.

    Alex

  • Paul Myron RPh

    Alex I think you are right that most people’s psycho-chemistry (does this word exist?) is based on events and their interpretation of events and how this causes the brain to react.

    For example, the release of cortisol when we are stressed. I can usually bring myself out of mild depression by accomplishing minor tasks that I have been putting off and once I’ve started this process I can overcome inertia and take on bigger problems. I may not be able to get complete resolution of the problem but I feel better just knowing that I’ve taken action. Is this raising my seratonin level? I believe it does. Of course I am lucky that I do not have severe problems with depression, many of which, I believe, are chemical in nature. Even though I’m a pharmacist, I really feel that antidepressants and most pharmaceuticals are grossly overused. I can remember a colleague telling me that the patients in his small town were not taking to the two new physicians who had recently replaced a retired GP. They were not sending people home with prescriptions for every complaint. He was not happy either because it had caused a depression in his business (which may have caused him to be depressed).

    Other issues such as placebo effect, efficacy, side effects, the wisdom of the older physician can be debated, but too often I see patients who are so overmedicated that most of their problems, both physical and psychological, are being caused by the drugs.

    I have just found you site and think it is wonderful. Please keep it going.

    Paul: Thanks for you comment and encouragement. Please spread the word about the site!

    Alex

  • Sandy

    Thanks Alex, I’m really enjoying your blog. I find it very comforting and encouraging. Thanks for sharing your thoughts!

    Sandy: I’m glad you’re enjoying it!

    Alex

  • T

    Your article seems insightful and kind, but the obvious question arises in response: what if the problem really is insoluble? It seems to me that many or most of the problems human beings encounter are not soluble—indeed are probably utterly beyond us—and so maintaining hope that we will solve them is futile. How does a human being solve death? Or the apparent absurdity of life? Or any one of the many tragedies and sufferings we must all undergo as we march toward a certain death? Life brings things that we don’t want and cannot avoid, and to try to convince ourselves otherwise seems to me to be an aspect of the very delusion that Buddhism seeks to dispel.

    The first Buddhist insight that “life is suffering” does not disappear after enlightenment. That suggests that depression, at least in the Buddhist context, cannot be banished in any permanent way by maintaining the hope that we will someday solve all our problems and no longer suffer. Perhaps depression is a profound state of insight into the futility of our efforts instead, and so a gateway to some greater form of enlightenment. I don’t know, but something about your approach here seems inappropriate and even lacking in compassion (maybe for you yourself) to me.

    T: I don’t agree that most of the problems that human beings encounter are not soluble. Nichiren Buddhism, in fact, represents a method by which you can develop the courage, compassion, strength, and life force necessary to solve your problems. Problems may not be soluble the way we want, but that doesn’t mean they aren’t soluble. With respect to the great existential problems you mention, I will certainly agree those are harder. Again, Buddhism provides answers to these problems but they’re not easily achieved, and may, I have to admit, not even be real. For me, at least, the practice of Buddhism is fundamentally about solving those existential problems. I haven’t done so yet, and will concede it may not be possible at all, but I am driven to try.

    Alex

  • JT, MFT

    I came upon your site through the NYT and was interested in “meeting” or knowing more about a physician who is Buddhist. I have always found it the only “religion” that is attractive and seems compassionate. I am dismayed at what I perceive as the facile dismissal of depression as simply inadequate thinking (forgive the truncated somewhat irritated summation).

    Clearly it is your desire to be helpful but there is a stubborn refrain here that disallows a deviation from your strong convictions. These convictions are like any religion, tightly held and unyielding. A parallel is Scientologists believe their methods can cure schizophrenia.

    No matter how much compassion anyone attempts to impart along with the belief that depression is basically caused by faulty thinking or beliefs, it will fail because it always leads to the ultimate conclusion: you aren’t trying hard enough or the too often heard, snap out of it. If it is not “easy” then it must be hard; if it is hard then it requires effort; if the effort fails it is not sufficient to the task; the obvious conclusion is you didn’t try hard enough. To compare spider phobia to major depression is off the mark. We are not out of the woods yet in our understanding of this illness. I agree with RG that is a spectrum illness, not an either or. It also manifests in various ways as well as degrees.

    I am a licensed therapist and also have suffered with major depression. Until I found a medication that addressed my particular disarray of neurochemicals—too little norepinephrine, not serotonin—I had recurring bouts of such extreme fatigue, physical and mental, I was at times non-functioning. I agree with all the ideas about some depression being helped by cognitive re-arranging, if you will, or good health habits, exercise, etc., but for those who cannot overcome this illness by those means it is unfair for them to have to perceive they are ultimately to blame. I realize you are not consciously intending that but that is the result nonetheless for claiming they just haven’t found the source of their powerlessness beliefs. (It is also possible to have powerlessness beliefs and not be depressed.)

    If medication ONLY cures symptoms then what of other illnesses for which we can only cure symptoms? Forgive me, but so what? Some diabetes is cured by changing diet, but not all, so we cure the symptoms. Maybe we will cure the causes one day as we have for other illnesses.

    I am of the opinion we humans are often inflated in our beliefs in our special powers of understanding. And we have done a disservice to many thereby. Surely we burned witches at the stake who probably had schizophrenia, bipolar disorder, or something similar, something that was not understood.

    It is a form of hubris for any helping professional to be unable to say simply, I don’t know. It would be far more soothing, and respectful, to me than you aren’t trying hard enough. If a doctor does not have a cure, he has not failed. If something works for some there is no guarantee it will work for all. Maybe some patients really do not put forth enough effort. Maybe some have a chemical imbalance that cannot be budged by these methods.

    Very few people are truly empathic about depression or those who suffer with it. Many therapists moan they hate working with people with depression; it is too tedious. Ministers admonish their flocks to avoid “negative” people.

    Hopefully we will find out more about all problems in the brain one day but until then, I am empathic and sympathetic to those who truly suffer with this illness. For me, the hope is more people will try to understand, be accepting of the person, supportive and not judge. We don’t admonish someone in a wheelchair: why don’t you get up and walk?

    (I wrote much more on this because I am passionate on this subject but have spared you the additional verbiage….)

    JT: I fully admit my theory about the true cause of depression is just that—a theory. But one that has support in my observations of many of my patients and which resonates with my own experience with depression. The point of my post was not to suggest an alternative treatment that leveraged the understanding that belief in one’s powerlessness over something causes depression (though I have found my own Buddhist practice effective in this regard). I couldn’t agree more with you that we should use whatever works—and that anti-depressants often work quite well (be careful about what you assume is the mechanism at work here, however—fixing imbalances in norepinephrine and serotonin have never been proven to be the reason anti-depressants work). I use them extensively in my own practice. Rather, the point of my post was to suggest that belief in one’s powerlessness to achieve something one needs to be happy is often depression’s hidden cause. As I stated in a previous reply to a previous comment, I find identifying and changing deeply held beliefs is often more difficult than overcoming many physical limitations. I don’t find, for example, introspection to be nearly powerful enough a method to awaken people to their most deeply held delusional beliefs.

    But that anyone would accuse me of lacking empathy for depressed people because I perceive the cause of depression to lie in delusion I must say demonstrates a lack of understanding of the depth and difficulty of reforming such beliefs. If you’re depressed because in your heart you believe you’re worthless due to a lifetime of abuse from caregivers, does anyone imagine overcoming such a belief would be easy? Or necessarily that harboring such a belief is the fault of the believer? Not I. A depressed person certainly may not be at fault for being depressed and should never be blamed. But are they capable of getting to the root cause of their depression and overcoming it. I say yes. I was hoping people would find this alternative way at looking at the cause of their depression useful.

    Alex

  • Mike Q

    Thank you for an excellent article and a fascinating forum of discussion. I think you are on the right track, Alex. What I am observing intuitively is that its not just a question of interpreting and decoding belief, it’s also a question of our personality orientation and how we both form and imbue our personal judgment into our interactions in the world and the meanings attached. What I have taken from my study of personality theory, and find particularly well reflected in the enneagram personality typology, is that at the core of every person is a basic belief about their relationship to the outside world. Essentially its a wounding so to speak, and the concomitant development of the person’s personality style from childhood involves developing certain traits and certain types of behaviour to compensate for it. In a certain light our personality type is a style of focusing, thinking and behaving to keep at bay awareness of a fear that we were particularly sensitive to in our early years. It becomes the theme to the story we tell ourselves about what is “really important” which supports behaviour choices we make. Something with a reflexive property that is so habitual its largely unconscious to someone. What I am wondering is if perhaps some of the misunderstandings about depression and its causes is brought about because it is experienced and manifests itself differently in many ways according to life situation and personality type.

  • Linette

    Alex, this is the first time I read your blog, and your article rings true with me. Since my 55th birthday 4 months ago, I’ve been overwhelmed with the feeling that my life is pretty much over. I feel increasingly irrelevant, and despite my accomplishments of an advanced degree, good job, and loving family (I’m a single parent), I ache with a loneliness and despair that I will never be able to have what I’ve always felt I’ve lacked. As I get older, I have to face the fact that it may never happen. I ask myself do I want to go through my the rest of my life feeling this bad? I feel if I could change my thoughts, I could stop the tapes that run in my head about worthlessness and unlovability and failure. I think that sometimes change can be acceptance of a situation or condition because not everything can be fixed. Is acceptance giving up? I don’t know. I’ve had years and years on and off therapy and at times I’ve been on antidepressants. I just want to be able to accept things I can’t change and find peace with that. But I want to be sure that what I think can’t be changed, really can’t be changed before I just accept it.

    Linette: Changing one’s thoughts is hard, but changing one’s beliefs is even harder. If “what [you've] always felt [you've] lacked” is something or someone external to yourself, you may or may not be able to attain it. But if you focus more on becoming happy yourself, on reforming the beliefs that are making you unhappy (which in my experience are most often not the beliefs you’re already aware of), inner change often brings about outer change. Not that I’m trying to proselytize here, but achieving this kind of inner change is why I practice Buddhism. You might want to click on the “SGI” link in my “About” page to learn more about it, especially if therapy hasn’t helped you the way you’ve wanted.

    Alex

  • Sean

    Does Buddhism really teach us to solve our problems? My understanding is that Buddha encourages us to become more deeply aware and accepting of the inevitable pain of living. It is precisely the resistance to our pain, the attempt to solve it, that perpetuates suffering. I know first-hand that depression is a bitch. But at the same time, I’ve come to recognize it as an enormous opportunity. Our pain demands that we pay attention! It teaches us to be aware…of who we are and what we are doing.

    I’m with you—depression is a profound contraction of the spirit, an attempt of the body and mind to hide from the emotional consequences of our belief that we are helpless, hopeless, worthless. But solving depression doesn’t work. Trying to solve a mistaken belief doesn’t make any sense. It just gives the belief that much more weight, legitimacy. You just make it more real. In that way depression is like a black hole. The more we try to fight it, the heavier it gets, and the stronger its pull.

    The great thing about deep emotional pain is that it teaches you that fighting negative emotions is useless and only makes things worse. Sooner or later, when you get really sick of it, you learn acceptance (which, I think, is another word for love). Depression deeply accepted has no power to harm. DT Suzuki, the noted Zen scholar, once wrote, it is only though the *willingness* to suffer that suffering may be transcended. Another Zen story…A master was once approached by a student who pleaded, “Please help me, my body and mind are burning.” The master replied with great kindness, “Go sit in the middle of the fire.” What a profound lesson. It may be that it is pain itself that opens us to our deepest potential for happiness. A broken heart is an open heart. Ultimately it is our wounds that heal us not the other way around.

    Sean: You’re describing the Zen Buddhist approach to suffering and depression, quite different from the Nichiren Buddhism approach, which teaches all suffering can be overcome by breaking through delusion. I’m afraid my own experience flies in the face of what you write: while I’ve never been able to change a deeply held belief by mere introspection, the core reason I practice Nichiren Buddhism is because I’ve discovered through experience with it that changing my beliefs is exactly what it does—by using the fuel of suffering as you describe. Each time it’s been a complete surprise to me to discover what belief was in fact causing my suffering, and yet each time, when my apprehending that belief on the deepest level occurred, I would later discover I’d ceased to believe it and ceased to suffer in that particular way.

    Alex

  • Howard Groesbeck (aka Jack Dakota--pen name)

    Dr. Lickerman:

    I am responding to the September 9th comments by “Helen of Hawaii.”

    Upon reading about her failed suicide attempt because the timber of her carport collapsed due to termite damage, I immediately recalled Kurt Vonnegut’s intention to sue the manufacturer of Pall Mall cigarettes for breach of promise.

    He considered the habit of smoking their unfiltered cigarettes to be a “classy way to commit suicide.”

    After smoking Pall Malls all his life, his guaranteed death from lung cancer failed to occur. He was disappointed and disillusioned by the corporation’s lack of integrity and by their blatant mendacity.

    Vonnegut claimed he was entitled to monetary compensation, since the company’s product didn’t kill him. He was still alive—and still smoking Pall Malls.

    Some of your readers may know the eventual cause of Vonnegut’s 2007 death: he slipped in his bathroom; his head struck a bathroom fixture; he fell to the floor—and died several weeks later from irreversible brain injuries.

    I wish there were even the slightest possibility of life after death, because I’m sure Vonnegut would still be chuckling about the manner of his departure.

    To date, I find Helen of Hawaii’s remarks the most memorable ones posted about your article. I have a very certain expectation she has a profoundly interesting personality and a valuable sense of humor.

    If she isn’t yet writing her autobiography, I hope she begins immediately. She may want to die, but I’m asking her to keep us company and share her story.

    With both your and her permission, I would like to correspond with her—if this is allowed and possible according to the rules of your website.

    You may give to Helen of Hawaii my email address. I will respond to her reply.

    Jack Dakota
    Skanee, Michigan

  • AGS

    Alex,

    Thank you so much for a wonderful blog and a great post. Your compassionate and thoughtful replies (especially to criticisms) are a reminder to me of what a dialogue could be.

    My personal experience of cyclothymia is well-aligned with the theory. Looking back, pretty much all of my “downs” came from some loss, some setback which led to me to lose the sight of the goals I wanted to achieve and felt like I couldn’t achieve and that it didn’t make sense to try. And as a result, much smaller things became very difficult, small decisions became unbearable.

    I also found it very hard to have people understand how certain beliefs can profoundly affect one’s experience.

    I would also extend your theory to explain hypomanias/manias, at least as I experienced them. Hypomanias come as a result of some of the negative, rigid beliefs breaking down. Once those depression-producing beliefs (walls) were down, I realized that I stayed in the cage for so long for no real reason and a lot of positive, productive energy got unleashed. That lead to productivity, search for new ways of living, new goals. Having read accounts of manic people, their experiences are similar, just way more extreme and having to deal with deeper existential/spiritual beliefs.

    This also led me to think more and more about attachments and reading your post on it confirmed my ideas. Attachments become a tight-rope. Too strong and depression follows if attachment is breaking. Too weak and there is no drive to take care of it. I found my cyclothymia mostly to do with cognitive processes—that’s why reading your blog is so fascinating.

  • Lucy

    Hi, Alex,

    Very interesting post. However I have to disagree with the following point:

    “I’d suggest an alternative explanation, that these forms of depression have a chemical or hormonal influence—reducing our ability to believe we can solve our problems but not entirely eliminating it.”

    I have adrenal insufficiency, diabetes and thyroid disease and have found that the ‘depression’ that comes with these illnesses is very much grounded in the physical reality of hormonal imbalance.

    Your brain needs both mineral- and glucocorticoids, insulin and T3/T4 to function normally. When you have too much or too little of these hormones, your brain simply doesn’t function properly. Simple cognitive tasks like word-retrieval or memory recall become very difficult when your brain doesn’t have enough hormones.

    For the hormonally-deficient, no amount of CBT, meditation or other therapeutic intervention will make up for the chemicals that are missing. When you start replacing hormones, it is like having a light switched on.

    The problem remains that artificial replacement of hormones is an inexact science and doctors remain over-dependent on blood values, paying little attention to how patients actually feel.

    It’s easier in these instances for doctors to say ‘it’s all in your mind’ than to question the validity of blood test results that simply capture one point in time and don’t convey the daily fluctuations experienced by the patient. Similarly, blood tests for hormonal values tell you what’s happening in the blood but don’t tell you how well the tissues are responding to hormone replacement.

    The best doctors for people with hormone problems are doctors who have personal experience of hormone problems. Doctors with experiential knowledge of hormonal disease do not make the kind of assumptions that you do about the personal coping skills of people who lack the hormones necessary to function normally.

    An easy way for doctors to test out their ‘it’s all in your mind’ theories would be for them to dose themselves up on carbimazole for a year and see how far their coping skills get them. Of course, I doubt there would be many volunteers.

    Lucy: You raise several excellent points. In reverse order that you mentioned them: 1) I completely agree doctors should listen more to how a patient feels than what their labs values say when there’s a discrepancy. “Normal” is defined by a gaussian curve; there is always a range in a population and what’s normal for one person clearly often isn’t normal for another, even within the so-called “normal” range. 2) I also agree that when depression has a hormonal cause that no amount of CBT, meditation or other therapeutic intervention other than fixing the hormonal problem will likely help. However, my point in the post wasn’t so much that these techniques would work in depression caused by medical illness but rather that the final common pathway by which medical illness causes depression might very well be by stirring up a belief in one’s powerlessness, thereby inducing a general sense of defeat. Though I remain confident that this belief is stirred up in all types of depression (whether the depressed person is aware of it or not) I’m far less confident that—and am still trying to work out if—depression caused by medical illness comes about as a direct result of it. I didn’t mean to imply one could think one’s way out of a medically caused depression but rather that even depression from a medical cause may occur via an effect on our beliefs. I view beliefs like physical things in their ability to resist our efforts to change them and their ability to affect how we feel.

    Alex

  • Jean

    Dr. Alex,

    I read a good part of this discussion. I didn’t hear any mention of mental illness (depression, etc.) being hereditary. It exists in three generations of my family, starting with—that I am aware of—my father’s nephews (brothers), four of my 7 siblings and me, in 2 nephews, 1 niece, and 1 grand niece. I have been chanting Nam-myoho-renge-kyo since 1983. Although my journey with bipolar depression has been arduous, it has been fascinating in terms of the gunk that has emerged and dissipated from my life. My life condition is light-years ahead of where it was when I joined. Mystically, I have discovered many deep-rooted, internal causes for my psychic pain. I have broken through them. I still purge on occasion, and I am mystified when I experience a bout of the same intensity as I did in years past. How do we account for the generational aspect?

    Jean: I’m not sure. Perhaps the tendency to be easily defeated, to conclude we’re powerless, has a genetic component or influence? Perhaps it’s something passed down from generation to generation by role modeling? Or perhaps some combination of both?

    Alex

  • uberVU - social comments

    Social comments and analytics for this post…

    This post was mentioned on Reddit by lwoodnj: Philosophizing about the causes is nice and all, but this seems to have little substantial evidence to back it up. I suppose if it inspires someone to do some research though it might be acceptable…

  • Dear Alex,

    I always think it is tricky for someone who has never experienced depression to write about what causes it or how best to attempt to cure it. I have a mild case (in clinical terms), but I suffered through 6 months of very little sleep and an inability to function normally—I could not have held a job—before I found a medication that, I feel, brought back the real me.

    Since I am naturally an optimistic person, and never gave up searching for a solution (I tried holistic therapies, exercise, meditation, acupuncture—you name it), perhaps I found my balance again quickly once the chemical problems were solved. However, until you have tried and tried to figure out why you are suffering, and then find that a daily pill relieves your suffering, I don’t know if you are qualified to suggest what is happening internally.

    I understand that you want to help people, but since depressed people tend to cling to possible solutions without a great deal of rational thought, please be careful when taking on this delicate topic.

  • Hi Alex,

    It’s me again. I just read more of your replies, where you describe dealing with your own depression. I didn’t know that when I wrote my first post.

    As I am sure you know, this is a sensitive subject, especially for those who have an ongoing problem. I’m sorry I didn’t understand your experiences before I wrote my post.

    Anna: It is a sensitive subject indeed. I’d hoped my ideas would be helpful to some as they were to me.

    Alex

  • Shantell

    Before I began to understand some of the things mentioned in this article, I would point to a series of events that occurred in quick succession as the cause of a long battle with depression. Only recently have I come to understand that it wasn’t the events themselves, it was my reaction to them. I eventually decided that there wasn’t much in life worth doing, because nothing I did made anything better. In short, I felt powerless.

    Since I didn’t believe I had power, I decided I didn’t care about much. If I didn’t care about people/things, nothing could bring me more pain. That, in itself, was it’s own kind of pain, because it also diminished my capacity for joy, which fed my depressed state.

    Perhaps because of my personal experiences, and where I currently am in my journey, I fully understand the points made in the article, even if I could never explain them as well. I’ve spent the last few years feeling trapped by my life, yearning for a freedom I couldn’t fully explain. Now I understand that the freedom I seek is inside me, and is not dependent on any external factor. The path to this freedom requires that I closely examine various beliefs I’ve held over the past few years. What I am finding is that many of these beliefs were tucked away in some nether region of my mind, yet still affecting my life in some way. In essence,I must free myself from delusions, as the doctor mentions above.

    “…we only relinquish our delusions when the pain that comes from continuing to believe them exceeds the pain of letting them go…” is EXACTLY what happened to me. I couldn’t have described it better.

    I had/have to examine how I really felt about various things. It was my thoughts, not the actual events (as painful as they were), that led to my depression. We often shy away from being completely truthful with ourselves regarding our feelings and beliefs, if we even acknowledge them at all. Sometimes we have to dig deep and find that we thought we believed one thing, but we really believed something else and the belief we haven’t acknowledged is the one that actually drives our actions and our state of being.

    Oddly enough, I could see none of this when I was in the depths of depression. It was only when I focused on trying to change one particular circumstance that I started to (very) slowly get to the point that I was ready to accept that I had to challenge some of my beliefs before I could move forward. Before I could search for answers, I had to understand what questions were necessary.

    Once we start down that path (which I imagine can be very difficult for many of us), we start to gain wisdom. It is key to being able to lead a joyful life even as life brings us painful experiences. At least, that has been my experience (and my uneducated opinion).

    I get it, even if I can’t articulate it very well yet. I just found this site today, and I am so grateful I did. So many things I’m reading either clarify things that are on the edge of my consciousness, or validate things I’ve already figured out. Thank you!

    PS—sorry to be so long winded.

    Shantell: You’ve articulated exactly the point I was trying to make. I’m so glad reading some of my posts has been helpful to you.

    Alex

  • T again

    This approach is, for me anyway, seductive, but it ultimately leads to more suffering. To regard life as a problem that requires a solution is a formula for more pain and frustration in life. Life is not a problem, although it is full of difficulties. Life is full of mysteries and dilemmas, triumphs and tragedies; these are not problems.

    I am speaking from my own experience, and everyone has to find out for themselves. My experience is that approaches like yours lead to more depression. I have suffered from “depression” (dysthymia) for much of my life, and the only sustained times of joy and peace for me have come when I let go of my Problem. I don’t mean give up, of course, but instead seek to transcend the problem in the way that art transcends life. A human being is a sacred cosmos, full of contradiction and conflict; and ultimately a far greater reality than the “problem” that one perceives.

    A great work of art does not expunge a life problem by solving it; instead, it uplifts the problem into its true nature, which is joyful, even when it is painful.

    “Better to have loved and lost…”, right? Is a broken heart, for example, a problem that should be solved, perhaps by erasing one’s memory of the painful relationship? I am a songwriter and singer, and I cherish my broken heart. :) I try to cherish all of life’s “problems,” if I can.

    “Accept honors and disgraces as surprises,
    Treasure great misfortunes as the body.”
    - Dao De Qing 13

    Treasure one’s misfortunes as one treasures one’s own body and one’s own life, because misfortunes and life come to us at once.

    T: I don’t disagree with much of what you’ve written here. I’d only add that while a broken heart itself may not be a problem that should be solved (and certainly not by erasing one’s memory of the painful relationship, even if one could), any suffering that results from it most certainly is and should be. Perhaps where we differ is in what we mean by solving a problem. To me, this simply means to cease suffering on account of it.

    Alex

  • Leslie

    I really like your article. When I lowered my expectations of myself and others my dysthymia lifted. I feel peaceful knowing that I am not a terrible person if I don’t live up to the expectations of everyone. I think perfectionism is a root cause of depression for young people that sets their mental health pattern for life.

  • Hippo

    You may be familiar with the following story, which I only recently stumbled upon.

    Before Pasteur and his germ theory, a prominent German obstetrician who had recently adapted Semmelweis’s widely-mocked chlorine hand-washing regimen became despondent, realizing that his previous unsanitary methods had likely caused the “childbed fever” deaths of many of his patients, including a beloved cousin. He committed suicide at the age of 51. Ironically, he was a pioneer; hand-washing would not achieve widespread acceptance among physicians for another two decades.

    http://en.wikipedia.org/wiki/Gustav_Adolf_Michaelis

  • Miriam

    I think there is a way to reconcile what you are saying and what the respondents are saying who disagree with you. Both you and they are looking at depression in a linear fashion—X causes Y. Or more modestly—X precedes Y.

    They argue that neurochemistry (and whatever caused its imbalance, be that health problems, genetic predisposition of, etc) preceded or caused the depression. You argue that a lack of belief in one’s ability to solve problems preceded or caused the depression which then manifested in imbalanced neurochemistry.

    Here is an alternate way of looking at it: See the depression as a circle/cycle rather than as a line. This circle/cycle can potentially be made up of 1) chemical imbalances 2) stressful occurrences 3) negative thought patterns 3) physical illness—add whatever you want to the mix.

    Depression occurs when enough of all of these factors—or a lot of even one of them—triggers a certain state in the body/mind. Once that state is triggered, it will take a certain amount of counter-measures to push one out of that state (or not—counter-measures may not be successful).

    These countermeasures will depend on what it was that figures most prominently in the depressive state (for one person it may be a preponderance of stressors, for another, a genetic quirk, for a third, a combination of many factors).

    One may choose to see these factors as cause, as precedents, as entry-pathways—or more simply (and less linearly) as those things that make-up/maintain the depressive state.

    The thing to avoid (no matter how one characterizes those things that are factoring into the depression) is trying to find one factor that explains all manifestations of the problem. For some people it will be one thing, for others it will be another, for others still it will be a combination of many factors.

    Likewise with solutions.

    In some cases it may be possible to counteract a depressive state (i.e., “break the cycle” or “break into the circle”) from a different aspect than the strongest factor—the “many ways to skin a cat” idea—when for other cases it must be a particular solution for a very particular problem (such as needing thyroid hormone for example, or needing time to heal from major surgery).

    In any case, if one looks at depression from a holistic, multi-factor, non-linear perspective, it takes one out of the need to argue a causally linear or even chronologically linear progression.

    In any case, the most useful thing to do (from a Buddhist perspective as well) is to approach each situation as an empty cup, not full of theories or opinions, but willing to listen and learn from what each individual situation has to teach us.

    I’m writing the above as someone who has both treated and experienced a variety of mood disorders.

  • jt, mft

    I appreciate Miriam’s comments. I would only disagree with one point and that is we are all thinking the same, as in a linear causal fashion. My position is we simply don’t know enough to really explain depression and/or any mental illness in exact terms, either about cause or cure. If one medication works better than another we can use that information to make a guess which neurochemicals are in play. But that is not the whole of anyone’s story.

    Something that persists in many such discussions is the assumption that depression is a single quantifiable illness and all experience it the same way. That seems to be part of the assumption it is caused by our flawed thinking of being powerless.

    The advent of medicine to address this has saved many lives both literally and in terms of lost time, wages, etc. Many depressions will simply fade with time. Many have depression that is so extreme it falls into psychosis.

    If someone is helped by looking at how they are thinking improperly that is good for them. But it is not one size fits all. For me, looking for the “why” was a dead end. It is a temptation and a habit for many. I try to think of the “what,” as in what can I do to help myself or with patients to help them. Sometimes in the latter case it is simply to be empathic, patient, understanding and supportive. That is a better suggestion to anyone than “you have to change your thinking.”

    I once wrote to Dr. Weil for his website post that depression was a problem of “attitude.” We don’t need to feed more judgment to those who don’t understand and who will try to “help” by giving advice to their friend or relative who is depressed and telling them both how they are wrong in their thinking and how to fix it.

    One of the only “causes” that seems reasonable to point to is the one of thyroid insufficiency which is measurable. For the rest we really simply don’t know enough.

    jt, mft: I agree with many of your comments. I would point out, though, that in putting forth the contention that a belief in one’s powerlessness is the true cause of depression I specifically avoided suggesting I know the best way to change that belief. As I’ve noted in the post itself and in responses to other commenters, I think changing one’s beliefs is one of the hardest things to do in life, especially when we’re unconscious of them or they lie deeply embedded.

    You may be right that depression is not a single quantifiable illness and that we don’t all experience it the same way. Psychiatry has attempted to carve out the different forms with different criteria and causes, but it’s done so at best bluntly. Yet there are striking similarities between all forms of depression that vary only in their severity: a feeling of anhedonia (the inability to experience pleasure), a feeling of being defeated, and a feeling of psychic pain. Why couldn’t those things, which seem to lie at the heart of most forms of depression, have a single, common cause? I could certainly be wrong about this (especially, I’m wondering more and more, with regard to secondary causes of depression like hypothyroidism), but I disagree that uncovering the “why” is a dead end. It may not immediately point to more effective therapies, but it very well may in the future.

    Alex

  • Kevin

    Alex,

    I was a professional at a major medical center, and I’d done well there for 22 years. But over the last two and a half years, my memory and ability to concentrate have been slowly deteriorating. Depression and a feeling of powerlessness to stop it slowly crept in as I began making bone-headed mistakes. I felt like I was either burning out, or had unresolved issues of some kind that needed to be addressed. I’d had some major emotional traumas in the past, so I tried using the self-examination and coping skills I’d learned from my previous time in counseling to deal with my current situation. I also tried slowing down and “being present in the moment” as much as possible. I kept kicking myself for not concentrating harder and began to feel worthless. In the end, things just got worse and I was terminated a few days ago.

    I stumbled onto your site via a link from the NY Times and have spent the morning having my eyes opened by your article and the resulting comments that followed. I’ll take your advice on how to deal with this and I also have a doctor’s appointment today and will insist on having various hormone levels checked thanks to Lucy’s contribution to the discussion.

    I think that depression occurs for several reasons, and the best course of dealing with it depends on the individual’s past and present experiences, world- and self-view, and/or biochemical equilibrium. I also believe that in some cases, there is a genetic component. You have a wonderful theory that I think may help many, but not all, people suffering from depression.

    Thanks a lot, and good luck paddling upstream against the current paradigm.

    Kevin: Best of luck in getting the help you need to feel better!

    Alex

  • S. Joseph, M.S. Psychology

    Dr. Lickerman: I read and re-read your treatise on causes of depression and your thoughts as to how to approach some resolutions. I agree that there are four or maybe five specific causes for depression. Also, I would put forth that only one of the causes the depressed person had/has any capability, in the beginning, to control. (1) Genetics—no control, (2) Physical injury—no control, (3) chemical imbalance—no control (save voluntary chemical consumption), (4) trauma—no control and (5) environment—HAS control.

    Long-term depression differs significantly from short-term acute depression, therefore making the chronic (long-term) depression infinitely more difficult to control. My personal opinion that the latter (chronic) is incurable, but treatable to the extent that the depressed has an excellent prognosis of living a full life after learning correct coping skills. This solution is most effective for those who have not learned the value of “escape mechanisms.” This ability to justify, substitute, etc. are the mind’s way of coping with situations that the conscious mind cannot bear to confront. Obviously, this does not solve these issues, but merely masks them so the individual can function.

    Psychotropic drugs, anti-panic and depression medications again only “mask” the issues and do not solve them. Solutions occur when the “unconscious” mind relays these issues to the “subconscious” mind. The unconscious mind does not address the conscious mind, but needs the intermediary to get the message across to the conscious. When these “epiphanies” occur, it can be extremely profound or extremely upsetting and dangerous to the depressed unless there is a professional monitoring so that the depressed is not so devastated as to harm themselves because of the revelation(s). Catharsis, and thence the healing process, can begin at this time, but I must stress that understanding and addressing these issues can be traumatic without professional guidance. I, personally have dealt with chronic, long-term depression for decades so if “it takes one to know one”, that applies to me.

    I no longer am involved with counseling but have many acquaintances who are and I pass this warning on to all. Learning the causal factor is the most important step, but is only the beginning of the solution. Thanks again for the insightful blog. Hope this is of some value. I am currently writing an article on this very subject, maybe a book. Depends a lot on my concentration level and I know you understand what I mean by that.

  • Elaine Falk

    Hello: I so enjoyed your article. My 33 year old son, an internal medicine doctor, working as a hospitalist became depressed out of the blue—he had worked 18 hour days for 30 days straight and was suicidal. His anxiety was off the charts and he had not slept in weeks when he asked for help.

    He was hospitalized for 6 days; his doctors put him on many antidepressants with reactions to all = he was released from the hospital worse than when he went in. He saw a psychologist for talk therapy and a psychiatrist for Paxil. The psychiatrist told him to stop the talk therapy that he would do both, which he did. He was encouraged to return to work asap—that would do him good; he signed a contract to open his own practice, was getting married, was leaving on a trip that night with his fiancee, and he killed himself.

    He said the depression was back and it was never going away and he did not want to be a burden on all he loved so much. I can’t stop thinking the medication killed him—also he felt like if anyone found out he was depressed he would lose his medical license—so I feel as if he had support from his medical community—including his psychiatrist—with just talk therapy he would have made it. Also over 500 doctors kill themselves annually—could this be due to going 40 hours at a time with out sleep, internalizing all of the pain as a very compassionate physician who never gave up on his patients?? I would appreciate any comments you have for me—I just feel like the medical profession—my son’s profession let him down—I know the medication made my son feel better but it did not change his irrational thinking—like giving a Tylenol for a fever but it doesn’t cure what is causing the fever, if that makes sense. My son was brilliant, scored highest in his med school class, perfect SAT scores, such a loving son and compassionate doctor, and quite a perfectionist.

    Thank you in advance,

    Elaine Falk

    Elaine: My condolences on your loss. You’re obviously aware that when people are transfixed by a deep depression their thought processes are profoundly distorted, as well as how the pain of depression plus the distorted thinking (“I’ll never feel any better, so to stop this pain I need to not be”) combine to drive depressed people to suicide. I can’t comment on whether or not the medical profession let your son down. He was under a psychiatrist’s care who I presume was monitoring him for suicidal ideation, but even then people who are truly determined to kill themselves often succeed. It sounds as if your son got caught in a dark rumination in which he couldn’t see how things might get better for him. You might be ruminating yourself over what you or others might have done differently, but the hard truth is that sometimes people do everything there is to do and still fail. Often antidepressants do lift people out of severe depression and that lifting up itself improves their irrational thinking—but sometimes the medication doesn’t work. Sometimes the feeling of being defeated is so strong it utterly overwhelms the people who feel it. I wish I could say more to comfort you. My parents have family friends whose son took his own life and they’ve been absolutely devastated by it. I can’t even imagine the degree of your suffering over this. The only other ideas I can think to offer can be found in a previous post, some of which you might find comforting, called Letter To A Widow.

    Alex

  • FS McDonald

    You present an interesting premise on the root cause of depression that I can see weaving through my own personal struggles with this dark shadow on my life. I know that being able to identify and take action on issues has been a part of my healing.

    At the same time, a major issue has been dealing with intractable issues that seem irresolvable. A current example that probably affects lots of people is the ability to secure employment in this economic climate. Many people are taking action to rectify this situation personally—by looking for work using various strategies—but at the end of the day, week, or month the depressing fact of being unemployed remains despite one’s personal efforts. This is just one example. I am sure there are others that would fit my description of intractable issues.

    Another influence that compounds these types of circumstances are the many permutations of mind-body theories, or Ophrah-fication, that essentially suggest change your thinking and everything else in your life will adjust accordingly. The main problem with this is that when it doesn’t work, a person then has more negative self-beliefs and social stigma for their failures.

    I don’t bring this up to justify my own mental state of victimhood, but as an honest question of how individuals can better cope with these problems. For myself, the best practice that I have had success with has been Tonglen meditation; I can’t change the ugly aspects of life, but I can be compassionate for the feelings that arise from it.

    FS: You raise several critically important points. I didn’t argue in the post that all problems are solvable (at least, not always in the way we want to solve them). I argued the cause is our belief that we’re powerless. Sometimes we actually are powerless (at least, to accomplish what we want in the specific ways we’ve been trying). I was only describing what I thought was depression’s true cause, not commenting on whether the feeling of powerlessness is ever justified or not.

    I, too, am highly skeptical that simply changing one’s thinking will automatically adjust everything in one’s life accordingly. Your comment about the risk that further negative self-views may result is spot on. Changing one’s beliefs, on the other hand, I do think leads to feeling and behaving differently, which then leads often to different results. Nothing magical about that, though.

    Thanks for your thoughtful comments.

    Alex

  • Kevin

    It’s a few weeks later and I’m doing much better. Apparently, I had a “perfect storm” occur. Family stress had increased during the previous period. Also, the anti-depressant that I’d been on had slowly lost its effectiveness, which affected my mood, memory and sleep. Cognition and memory are affected by decreased sleep and depressed mood. All this affected my job, which only increased my anxiety and deepened my depression. By now you’ve guessed that I’m talking about a really nasty vicious cycle. I was too impaired to even realize what might be going on.

    Finding the problem(s) and working out a plan to fix things did much to enhance my outlook. And switching to a new, much more effective medication has been wonderful. “Better living through chemistry” isn’t the only answer for me, but it sure has helped in the short run.

    I had let things go to far before getting help. I hope others can learn from my experience.

    Over time, I’ve found several things I can do on my own that help a lot when dealing with depression.

    One is to try to see the big picture. We live in an inconceivably vast universe consisting of over a hundred billion galaxies each averaging over a hundred billion stars. Comparatively, our planet is less than a speck of dust. And yet we, specks on our planet, are able to comprehend this vastness and our place in it. Right now, you and I are conversing via electronic media about the nature and workings of the human mind. And we are doing so out of concern and compassion for each other. Whether we’re alone in the universe or not, and whether we’re here by divine or natural processes, we’re damn special. Another way of looking at the big picture is to consider how lucky we are to be living in this time and in a country where help can be gained. Also, a spiritual approach can be helpful; I don’t need to go into detail here.

    The second thing I’ve found that helps to deal with depression is to work on physical things in your life that need to be repaired, maintained, cleaned or improved. Completing a task is an achievement, something to feel good about. And while doing it, it keeps you from dwelling on problems. Pick a closet, empty it, throw out the junk, give away some stuff, and put the rest back in an organized manner. Repeat as needed throughout the house or apartment. Same for cleaning or painting or maintaining stuff. Bite off a small, clearly defined chunk, deal with it, and move on.

    Exercise is a real help. Get some good shoes and a buddy to walk with, lift some weights (free weights are cheap at a lot of stores), do sit ups and push ups. Just don’t go to extremes when you first begin. But DO begin, and keep at it even when it’s the last thing you feel like doing…which will be most of the time. Exercise enhances mood while you’re doing it and in the long run. And you’ll look and feel better physically over time. Also, if you have kids, you’ll be setting a good example for them.

    Finally, cut back on junk food. I did and I had more energy pretty quickly.

    The activities I’ve written about can’t fix depression, but I think they are things people can do on their own to make things better for themselves while dealing with their emotional situation.

    Kevin: Good tips, all. Glad you’re feeling better.

    Alex

  • Patrick

    Well done, Dr. Lickerman! I was directed to this discussion by a friend’s blog, and I like what you’ve achieved here so much that I simply had to comment. As to whether your theory can successfully be applied to the cases of depression that have medical causes (i.e. hormonal imbalances, hypothyroid, major medical, etc.), that’s an open question for me: perhaps the mechanism of how those depressions develop is the same, although there’s an underlying medical irritant that causes the problem to develop where it otherwise would not. As to the implications of your theory on the cognitive variety of depression however, I personally think you’ve got an absolute winner.

    I suffered moderate clinical depression for five or more years. I was never hospitalized, but I went through about 5 different medications over the course of the first year or two after diagnosis before finding one that worked consistently for a while (Paxil, at the suggestion of an aunt who had also suffered). Some of the early medications certainly made the problem much, much worse. What I tell everyone who asks is that medication in my experience—on the whole—bought time: I believed that I could take a pill and thereby get through the next day. Having something external to my near-totally disabled self upon which to rely for strength, I then used that purchased time in therapy sessions and on my own to eventually buy a more permanent measure of freedom from the illness. I have been medication-free for the last eight years. Not perfect: I still have down periods that I describe as “petit-mal,” but absolutely nowhere near the horrendous conditions of the past.

    My personal path out of the spiral of deep gloom was very much about my beliefs, and learning to change them *over time*. I would say that my depressive experience is a story about tangled, snarled beliefs that both prevent me from achieving my goals in life and also prevent my having healthy goals and habits in the first place. I say “is” and not “was” because I don’t think that I’m done changing my believing: while I’ve surmounted quite a few already, a couple of belief problems remain to be solved. For instance, I’m in my mid-thirties and I still have *absolutely* no idea how I’ll find a mate. Not like I’m not attracted to many women; more like I just don’t have a working mental model for how to believe that I can find a right, or even acceptable, person, and/or that I’ll be right or acceptable to anyone else. If you read that sentence and didn’t really get how that could possibly be real or relevant in anyone’s head, consider yourself lucky: that’s one awful belief problem you don’t have. In the old days, I would have focused on it, tried to “sort it out” and ended up sinking with it right down to the bottom of the ocean, hopelessly and debilitatingly snarled in the same weighted net with which I had insanely tried to free myself. Now, when it comes up, I acknowledge the pain that it causes, and I put it right back on the shelf quickly: without the right key in hand to unlock the problem, I am simply and totally weakened by it—just like Superman holding kryptonite. AND, just as importantly, I remain firmly rooted in my new belief, my protective cloak: I will, in time, uproot all of these erroneous and dysfunctional beliefs, or live trying.

    One of the funniest things about my therapy experience in retrospect (which may be helpful to some of your readers, since it seems to me that we nearly all have some direct experience with depression in some form) dovetails exactly with your statements about potential solutions that we *believe* to be unacceptable for whatever crazy reasons we may have. The first thing I ever said to my therapist was, “This isn’t about my father.” And while it may not have been *only* about my “problem-drinking, periodically-violent, son-of-an-alcoholic, religious-addict, extended-family-and-friend-relationship-destroying, master-manipulator, zealously-self-centered, supremely-controlling” father, it most certainly *was* about him; well more than half. But what I said there, in those first seconds of my very first therapy session, illustrate the problem perfectly: I unconsciously held the iron-clad belief that solutions to my depression problem could not possibly involve examining my father’s role in my upbringing; as there was no other way to get healthy, I concluded that I was powerless to solve my problems, and I suffered. In the ensuing years, I did eventually confront my father’s role in my problems, and in so doing, I won for myself a big chunk of my spiritual and emotional health that I had never previously possessed.

    To all those who have railed here against perceived suggestions that they should just “sort it out” or “change your attitude” or “just snap out of it,” let me say that I completely understand your sensitivity. Our society, despite being riddled with depression, has very little patience or sympathy for it. For example, should one end up in a hospital for treatment, there are many who consider those people permanently damaged somehow—and that’s just really sick. The way I figure it, if you can beat depression, you’re actually of the strongest possible stock. No, what’s being suggested here, as I understand it, is not at all a simplistic question of changing your thinking; this is something much more complicated, subtle, and, yes, even spiritual: changing your believing.

    Apologies to all for the long post. And to those suffering, I’ll close with the following hard-won advice: Forgive yourself first and always. Do what you can, when you can, and give yourself permission to forgive absolutely everything else.

    Patrick: What a wonderfully articulate comment. I’m so encouraged by it, especially by your grasp of my main point, which you so well expressed when you wrote, “…what’s being suggested here…is not at all a simplistic question of changing your thinking; this is something much more complicated, subtle, and, yes, even spiritual: changing your believing.” That is exactly it. Thanks so much for such a great contribution to the discussion.

    Alex

  • [...] a friend or family member to suicide, I have lost a patient (who I wrote about in a previous post, The True Cause Of Depression).  I have known a number of people left behind by the suicide of people close to them, however.  [...]

  • Julia

    As an anxious person who lost 2 years to cancer treatment and is now NED (no evidence of disease) I became depressed for first time after final surgery. At first I thought feeling was sadness. But feelings of defeat and lack of vision for future (I live from one oncology visit to the next) continued. I’m terrified of re-occurrence and have watched people die painfully from cancer. Sometimes I wonder if depression is my brain’s way of dampening the anxiety over death/re-occurrence? I’ve tried SSRIs/NIs which have upset stomach and left me feeling either jittery (more anxious) or zombie-like. Although these meds are often prescribed for anxiety I’ve been told that in socially/physically active people they can cause mania? Thus taking meds makes me more anxious. My moderate use of diazapams have been criticized. However, I still feel like a less fearful me. Ideally I’d like to be med-free. Also very helpful has been tai chi/qigong and energy work in general. I’m curious if there are other primarily anxious folks out there who have experienced depression as a “dampening effect?”

  • [...] I wrote in a previous post, The True Cause Of Depression, many things can trigger depression, but in my view the underlying common cause of almost all forms [...]

  • Julia Kogan

    I just LOVE reading your blog.

    Thank you!

    Julia: I’m so glad you do.

    Alex

  • [...] is, our minds—are also “two but not two” (as I discussed in a previous post, The True Cause Of Depression), so the idea that an emotional disturbance could be translated into a physical symptom [...]

  • Eve

    I had read your “Good Guy Contract” and thought it was tremendous. This post however doesn’t resonate with me at all. Like Helen from Hawaii, I have been depressed my whole life. I am 44 now and have pulled myself out of heroin, cocaine and alcohol abuse that started at a young age due to abuse and neglect as a child. I overcame years of agony and rebuilt my life. Stopped all drugs, lost 50 pounds, got a job for the first time in 15 years with no social or marketable skills. Where at one time I was afraid to leave my house, I flew to London by myself. I had hope and wanted desperately to meet someone and marry and have some kind of a love bond, I had never had one at 40 years-old. I ran right into the claws of a psychopath. For two years he was the most wonderful person in the world, who made me feel loved and important to someone for the first time in my life. He met my father and told him how much he cared for me and we talked of marriage. My father liked and approved of him and talked with him on several occasions. That’s how good his mask was. I felt happy and loved for the first time in my life. I felt that all my suffering was worth it for what I felt and for the future which I was looking at. Then he showed his true face at a time when I was most vulnerable and after he had gotten all the pleasure out of playing with me. It was all for a joke. More than two years to get a woman to love him and play with her mind FOR A JOKE between him and a friend. He broke it off with a 2 minute phone call and said he was out of minutes. He stopped contact and 5 weeks later wished me Merry Christmas and Happy New Year in an email. He also said in that email that he was tired of playing with my life.

    I got no support from my family, they blamed me. I have since stopped contact with them. I have no one.

    That was 2 years ago. I have tried meds, therapy, yoga, meditation, exercise, nutrition. Someone mentioned sex, haha, yeah if I could ever have it again, I’m sure it would be nice.

    I’m a 44 year old-woman who had never felt loved in my life and now I feel I never will.

    Conversations about what causes depression at this point, for me, are useless. I have overcome things that most people can’t imagine and my spirit is now broken. There are limits to what a human being can take.

    Eve: How horribly and cruelly you were used and abused. No wonder you feel bereft of hope. And I completely understand why any conversation about what causes depression would strike you as useless. What you need, of course, is a means by which to lift yourself out of it. It does absolutely no good to understand that a deep-seated belief in one’s powerlessness is at the heart of depression unless one is given the means to break through it.

    As horrible as having your family blame you for what happened, you don’t need their support to win over this obstacle and find the most important love available to you—your own. It’s far easier to let go of hope to feel better than to allow that hope to remain and thereby remain vulnerable to disappointment when you try something and are let down. I firmly believe, however, there is no depth of suffering a human being can enter that he or she cannot be pulled out of. For me, the method that has worked is the practice of Nichiren Buddhism. You may not feel that it’s for you, but I would encourage you to explore it. Or if not, I would encourage you to explore other methods, to not give up hope that you can feel better. The feeling that you will never be loved in your life is an illusion. You may not be, but if so, only because you lacked the courage to attempt to transform yourself rather than those around you. Please summon your resolve and fight to win over your despair. All life-conditions, ultimately, are temporary.

    Alex

  • Julia

    Eve, I think you’re amazing. Hope you take strength in your ability to change your life around. Few are able to do so after enduring such trauma. Applaud yourself! I’m so sorry that you were badly deceived in your romantic relationship. And tho’ this may be cold comfort, I encourage you to look for love in different places. We all naturally turn to family or one true partner for love. However, that doesn’t always work out for reasons that have nothing to do with us. When I have felt alone in the world, I open myself to love in general. Sometimes it comes in odd packages from unexpected places eg: at teacher at a continuing ed class, friends in my Faith & Feminism book club, participants in my Tai Chi club. And while I’m not suggesting that this love replaces romantic love, it’s still of value and leads to a feeling of “connectiveness.”

  • John

    Why are you ignoring the cases where someone simply doesn’t have adequate control over their situation, not due to their beliefs; I’m talking about the cases where someone is being completely honest and accurate about reality, is living a crappy unfulfilled life, and can’t do anything about it.

    What about those cases?

    John: I disagree with the premise that in any crappy, unfulfilled life a person can do nothing to change, even if not their situation, then themselves and their view of it. Perhaps they’ve examined all the possibilities they can see and find them all “impossible” or unacceptable for one reason or another (perhaps they’re unwilling to risk a loss, etc.), but there are always other solutions. They may not be the ones the person wants—they may not involve the person wresting the control over their situation as they desire—but mood is not inevitably tied to circumstances (how was Viktor Frankl, after all, able to maintain hope while imprisoned at Auschwitz?).

    Ultimately, of course, issues of existence press down on us: we’re all going to die, for example. How does someone who’s depressed over that issue solve that problem? An entire book could be written about that, but the short answer, in my view, is that though the fact of death may destroy us, the idea of death may even be the cause of happiness (to paraphrase Irvin Yalom).

    Alex

  • Julia

    I’m also a fan of Viktor Frankl who said we can’t chose our circumstances but we remain free to chose our response. He also addressed the need to have a guiding purpose to keep us going during dark times.

    Yes! I would like to see a book written on the topic of depression and death. As I age….As more friends and family die off…. I find myself increasingly thinking about death. And my fear and dread increases.

    Am not sure I totally get the comment by Irvin Yalom and would like more background about both the context of the remark and the man.

    Julia

    Julia: Irvin Yalom wrote a book (one among many) called Staring at the Sun in which he argues our response to our knowledge of our mortality may function in a positive way, creating value rather than fear in our lives. I’m not sure he has the right formula for making that happen, but I do believe in the possibility.

    Alex

  • Eve

    Thank you Alex and Julia for your kind and insightful replies. I have gone back to counseling and I’m starting EMDR therapy. I have also joined a few meet-up groups and forced myself to go alone to a Christmas party last week. I want to go to school and am looking into it. I am also looking up the Nichiren Buddhism and transcendental meditation. I don’t want to be beaten by life.

  • Julia

    I’m going to my fourth memorial/burial of the year today. The deceased, my mom-in-law, died of breast cancer, a disease we shared. I’m curious how those—who fear death as I do—COPE at funerals? They not only remind me of past deaths but put me in touch with fear of my own. Thanks.

  • Eve

    Julia, I don’t know if this will help, but I wondered if you ever read any philosophy books regarding death. I find some real help and comfort reading things like Epictetus and other Stoics. You could do a search on philosophy and death and see if you find anything helpful. I don’t think you can beat all those old guys when it comes to trying to find ways to cope; at the very least it gives you lot of viewpoints to consider.

  • Julia

    Thanks. I’ve read books and essays but none recently. Need to re-visit each time fear resurfaces. Thanks for your recommendations. I’ve not read the Stoics but will now. Interestingly what I miss most about the dead is their voices. I have pictures, emails/letters, and memories. But it’s the silence of the grave that breaks me.

  • Toni

    I just discovered this site, and I’m grateful for the information I’ve read so far. I do have a question: I have battled both depression and anxiety for years, and just found out within the past 12 months that I have ADD on top of everything else (I’m in my early 50′s). I’m also perimenopausal, but that seems to be more annoying than anything else. I feel trapped and helpless in my life, and totally understand the “not wanting to live but not really wanting to be dead” theory. The pain is overwhelming at times, but thinking of my sons keeps me from doing anything permanent. No one, not family, not therapists, not anyone understands my hurt, because I don’t talk about it, assuming that no one really wants to hear it. When I allude to it, all I get is “it can’t be that bad.” It is that bad. I feel powerless to change and I don’t know how to think myself into happiness. Any suggestions on how to cope with this? What should I tell my therapist so she can better help me with my problems? I’m tired of being in pain and feeling alone.

    I hope someone out there has a suggestion or two. This is the first time I’ve been brave enough to even write about it.

    Toni: I’m so glad you did write about it. The despair you’re feeling absolutely can be managed and even resolved. If your therapist, of all people, isn’t interested in hearing about it and addressing it or says, “It can’t be that bad” then frankly you need to find a new therapist. The historical reasons for feeling depressed as you do are hugely varied and often need to be apprehended in order for you to free yourself from the feeling, but not always. Also, in the right person, antidepressant medication is enormously helpful. Finally, I would offer you the practice of Nichiren Buddhism, whose central aim is the self-discovery of the jewel that resides inside us all, a discovery that brings with it an enormous sense of power and confidence and even joy. You can read more about it in The Buddha in Your Mirror. Best of luck. Don’t give up hope to feel better.

    Alex

  • Eve

    Toni, I’m sorry you are feeling so badly, and I know how you feel. It does no good for anyone or even ourselves to try to think “it isn’t that bad.” As you say, it IS that bad and we have to start there. Trauma put me in early menopause (going through it now) so all the things that come with that certainly can add to an already overwhelming burden. I agree, if your therapist is making you feel that you aren’t being heard, you should tell her that. Tell her that you need her to take your situation seriously, or you should find another. Our feelings have to be taken seriously. Can you speak to your family and let them know that it hurts you when they don’t listen and support you? That it would help you greatly if they could? Online support groups can help; at least you can talk to others in the same boat and help to lift each other’s spirits. Just having our feelings validated by others can give relief. Do a search for online support group depression. Also any little thing that makes you feel good mentally and/or physically, do more of it. It’s very important to try to care for and even pamper yourself a little. Take long hot baths, walks, or whatever it is you enjoy doing. Relaxation techniques, like a yoga DVD, meditation—you can find guided meditations on YouTube. Some kind of exercise/activity is important, it really helps with depression. You are definitely not alone. Be your own best friend and get your needs met, really care for yourself, take small steps. Hugs to you and I hope you find some relief soon.

  • Toni

    I didn’t mean to make it sound like my therapist won’t listen. I’ve never brought the subject up because I didn’t know how to. She definitely listens (I’ve had a few therapists and she is absolutely the best). I just wanted suggestions on how to bring the subject up with her. Thanks for everything else. Just knowing I’m not alone has taken the despair down a few notches…

    Toni: Perhaps you might start with your therapist the way you did on this blog. Simply do your best to express what you’re feeling exactly as you’re feeling it, without any editing to soften or mute what it is. Even express your sense that others in your life want to downplay what you’re feeling and how that itself makes you feel. A good therapist can handle all of that and further needs to know what you’re feeling to help you deal with it. Good luck!

    Alex

  • HowToLiveHappily

    Toni: It was sad to read about your suffering. I hope that you did talk with your therapist and have gotten the help you need.

    Even sadder though is the fact that you have been afraid to speak up for so long. We’ve been taught to be ashamed of expressing our emotions and needs. How unfortunate!

    Hopefully, you will learn to open up and realize that you don’t need to feel ashamed or guilty for having needs.

    I suspect that your fear of expressing yourself has been playing a major role in your depression. You’ve been taught things that were not true, and you still believe them.

    It’s important to realize what these things are and reconsider them. Have you ever heard of limiting beliefs? They are lies that appear true to you and ruin your life.

    Maybe you feel depressed because you believe in imaginary hurdles that seem to stop you from getting your needs met. As soon you realize that these hurdles are not real, your depression will be gone.

    I wish you best of luck!

    Alex Lickerman: Thank you for the amazing article! I love the way you define depression. I also believe that medication can’t be a permanent solution, and only can give you a boost so that you can find a solution to the real problems.

    I also believe, that many of the problems are just imaginary. Our minds are playing tricks on us. As long as we become aware of the illusory nature of our problems, the depression dissolves.

    What are your thoughts on this?

    HowToLiveHappily: No doubt we often inflate issues before us into problems when they aren’t. But many problems we face are very real with very real consequences for suffering. I think it’s important to recognize when we’re inflating an issue that isn’t an issue and when we’re denying our own suffering as a means to conquer depression (which doesn’t work).

    Alex

  • Alex Lickerman – The True Cause Of Depression « How To Live Happily

    [...] by howtolivehappily on February 2, 2011 I just came across an amazing article about the true cause of depression and would like to briefly mention a few points it makes. This is by no means a complete summery. [...]

  • [...] Depression Is a Wake-Up Call by howtolivehappily on February 7, 2011 A couple of days ago, I posted a short summary of an article about the true cause of depression by Alex Lickerman. [...]

  • Malachy

    HI
    I identify as a Buddhist, a survivor of childhood trauma and as a grateful recovering alcoholic/addict. I could not have imagined having a better life than I have had for the past 16 plus years…I’ve been under medical treatment for major depression for 14 of those years. My depression has nothing existential, attitudinal, philosophical or spiritual about it. It manifests as a true neurological gestalt: the nerves in my skin, esp my face, seem to go dead. I feel carved. My brain and my body moves in slow motion, I sleep too much or not at all. My emotions and outlook would not be affected at first.

    Before I took meds—this would over time—spiral into a distorted painful place that I would just have to wait out. I exercise often, eat well, and have loving healthy relationships, creative musical and literary pursuits. I meditate, pray, do yoga, community service, etc. I would say: “My life is so good, why do I feel so bad.”

    When I first took SSRIs, I was amazed! Many of these symptoms did not go away but became more manageable. The pattern seemed to be: a drug or combination worked for 2 years or so, then slowly stopped working. We would try higher doses, with some relief, then back to that wooden feeling. Try new combinations that would work for awhile. Whenever I went off meds, I would soon start to have that crippled feeling. I moved to Hawaii, thinking the sunshine would help. With medical and psychiatric advice, I weaned off all the meds, thinking I had a seasonal problem, but got trapped in the worse depression and insomnia downward spiral I have ever experienced.

    I treasured my life: partner, child, great job, loved being in the ocean every day, had wonderful recovery community, but my distorted reality became so painful I attempted suicide. I obviously survived. When I got out of the psych hospital I was put on a new drug for bipolar depression, which I didn’t think I had and the doctor didn’t either, but he had no idea what to do next. To both our amazement, my depression has been gone now for over 2 years—not better, but gone! I still have occasional insomnia, but I live my life depression free. My attitude, spiritual understandings and practices, loving relationships, etc have not changed. My brain chemistry has.

    I think we do a disservice to many people who have this chemically based brain disorder we call depression when we wax philosophical, framing it as related to some kind of outlook on life, faulty understanding or spirituality, an existential dilemma, etc. Some may perish trying to find the answer many so blithely propose.

    Malachy: A few comments. As I mentioned in the post, antidepressant medication is often life-saving, as it seems to have been in your case. To conclude however that such depression is purely the result of a “chemical imbalance” doesn’t necessarily follow. On the other hand, even as I advocate for a belief in one’s powerlessness in some critical area as the underlying cause of depression, I don’t argue that it should only be attacked psychologically or spiritually. Far from it! I have my own cadre of patients just like you who were only (and dramatically) helped by medication. Whether some neurological deficit goes awry first or not, I still think such a deficit leads to the common denominator of a pervasive sense of powerlessness, that then leads to all the other feelings you describe. I wouldn’t want anyone to think overcoming a firm belief in powerlessness only requires a strong will, as it clearly doesn’t. Nor am I suggesting one can’t arrive at a firmly entrenched belief in one’s powerlessness as a result of a neurologic abnormality—an abnormality that can be treated (though importantly not cured) by the administration of an antidepressant medication. The post was meant to explore the geography of depression only and I fully admit as a working model it may not fit all cases.

    Alex

  • Alex Lickerman – The True Cause Of Depression | - How To Live Happily | How To Live Happily

    [...] just came across an amazing article about the true cause of depression and would like to briefly mention a few points it makes. This is by no means a complete summary. [...]

  • Jennifer Hall

    I think you should read this article: http://www.springerlink.com/content/r3802h26364n7582/, which I think is true of any/all suicides. This is the point that everyone needs to grasp about human beings. No matter what anyone does, you can’t ever “force” someone to be “happy” or to want to live. That is and always will be only in the control of that individual; which is why we should not wallow so much in our guilt if someone commits suicide, because that is and always will be beyond our control. We can’t literally control someone else’s mind or free will; unless you want them to eternally be your slave, which is immoral and unjust in my opinion. I personally think we should all be free to live or die based on our own opinions, so long as we don’t directly hurt others when it’s not necessary.

    Jennifer: You might read this post if you haven’t already: The Six Reasons People Attempt Suicide. Also, I wonder a little about your last comment: how many people are so disconnected from others that their suicide wouldn’t harm someone?

    Alex

  • Dear Alex-

    I so love reading your insightful posts! I have several Dr. friends I’m going to point your way. It seems in our fast-paced, over-stimulated society depression abounds. I too, have been there. I really like that you pointed out how much it matters what we think about and that there is scientific data to back it up how it affects the physical body. I wrote briefly about “mind discipline” in my blog. It really makes such a huge difference in the quality of life. I also appreciate you mentioning the chanting. While I am not a Buddhist, I believe there are huge benefits to emptying or freeing one’s mind through practices such as chanting, meditation, prayer. Our lives are so filled with noise…to set aside that time of quiet reflection is revitalizingly essential.

    Thank you for your comments to Ms. Osment. She is in a very difficult situation. I was a child of 8 years-old when my father died of gallbladder cancer at the age of 51. I watched him gradually decline and suffer and go in and out of the hospital. I remember tears rolling down his cheeks. I totally agree with you that as difficult as it may be, it would be wonderful if she could do everything she can to ease the process for her daughter. Enlist the help of a professional to give her guidance and ideas to make a profound and lifelong impact and legacy for her daughter. It would be her greatest gift.

    Thanks again for your rare wisdom and insight!

    Faith

    Faith: Thanks for your comment and for reading.

    Alex

  • Eve

    I have an update. I finally tried an antidepressant: I’m on Cymbalta now. It was really rough for the first couple of months, but it does seem to help with mood though and also with pain. I have chronic pain and it really helps with that. I was at the point where I would have one good day and then five bad ones, over and over. I still have bad ones, but more good ones. I didn’t want to try an antidepressant, but I was at the point where things just could not go on as they were. I’d tried many things and nothing was working. I have since found out that apparently trauma can mess with the neurotransmitters or chemicals of the brain, so if that is the case, an antidepressant makes sense for awhile. I will have to taper very slowly though when I want to get off. Good luck to the others here on their journey. Alex, I am learning about Buddhism now too. I am continuing the inside work, I do not consider the antidepressants as a cure all, just a way so that I may be able to function and do the inside work that is needed. I think this is very important.

    Eve: I couldn’t agree more. I’m glad you’re feeling better.

    Alex

  • Cindy

    Just got routed here by a NYTimes piece you commented on. Reading this post, I was struck by one thing: how little it applies to children and young adults with depression. Talk about being largely powerless to change your circumstances. And talk about having a load of possible things in life to get depressed about.

    Even as an adult, you can’t make money grow on trees, up and leave the horrible boss, magically rid yourself of a chronic disease. You can only make plans to deal with problems.

    What I’m saying is that in some cases we are too quick to pair depression with “must cure it!” We overlook the transformative power of going through depression. Unless someone is dysfunctional or going to harm themselves, consider stepping back a bit from intervening in a person’s depression. Some people benefit more in the long run from going through depression than they do from interventions meant to ease it.

    I also don’t think we are creative enough in addressing cases of depression, but that’s another topic.

  • Zoe

    I’m 20 years old and have been taking antidepressants since I was 16. I’ve tried all different classes and recently my doctor had me take a supplemental antidepressant to see if the two would work better together—we thought one would counteract the side effects of the other.

    I’ve reached another wall, where I feel that the antidepressants are only holding me at a certain, slightly-below-adequate emotional state. The medication was initially incredibly helpful, really life changing. But I’ve grown and changed a lot since then. I’ve been using these drugs as a reason not to work on curbing my overly sensitive reactions to certain situations and my moment-to-moment emotions. They’ve given me an excuse.

    I just started experiencing some bad anxiety. It leads me to realize that dealing with anxiety and depression is far more than adding a new drug, or changing the ones I’m on. It’s time to put real effort into investing mental and emotional energy into reworking my cognitive patterns. When I was in the hospital for treatment for an eating disorder years ago, CBT was the most helpful. I didn’t think I could apply the same techniques to help my depression.

    This article felt like a deep breath. Thank you for sharing your thoughts.

    Zoe: I’m so glad you found the post encouraging. Best of luck to you.

    Alex

  • ATT

    I was wondering what you meant (in a response to RG above) when you wrote that you don’t tend to consider options outside what appear to be the limited ones available until you are “forced” to do so. Do you mean that you tend to hover in indecision between limited options until you run out of time and are forced into your dilemma, and then you suddenly find yourself discovering a new option? Or do you mean that you tend to grind away at one of the horns of the dilemma for a while until you can’t stand it anymore, and then you decide to abandon the whole thing and move in a new direction? I am wondering how these previously “unacceptable” options are revealed… Are they revealed usually because you finally learn through experience just how bad the “acceptable” (limited) options are?

    ATT: Usually it’s the severity of the pain a situation is causing me combined with the failure of the solutions I’ve tried that finally impels me to open my mind to solutions to which I’ve previously been closed.

    Alex

  • Alex Lickerman – The True Cause Of Depression - How To Live Happily | How To Live Happily

    [...] Depression by howtolivehappily on February 2nd, 2011 I just came across an amazing article about the true cause of depression and would like to briefly mention a few points it makes. This is by no means a complete summary. [...]

  • Depression Is a Wake-Up Call - How To Live Happily | How To Live Happily

    [...] Depression Is a Wake-Up Call by howtolivehappily on February 7th, 2011 A couple of days ago, I posted a short summary of an article about the true cause of depression by Alex Lickerman. [...]

  • Dan

    Karen’s contrast of responsibility and guilt is laudable. Our puritanical roots encourage the notion of responsibility, but as someone who comes from a chronic care family, I’ve known since childhood that much of our lives are beyond our responsibility. Andre Agassi helped clarify this, when he discussed taking ownership of his issues—as a tennis player from age 3, responsibility was not his, but he became empowered taking ownership of his history. Just as you have to set a bone if it’s broken, depression may be part of the path to our own awareness, forgiveness, and acceptance. Our culture doesn’t even really have a vocabulary to discuss our emotional lives and well-being!

  • Sherri

    OH this article rings true on so many levels. This is what I tell the suicidal people who call the hotline all the time… what we think actually changes our chemistry significantly. The worst culprit being guilt and self flagellation over our mistakes. The other close culprit being fear, which although motivating to some, freeze others and they can’t see past it. I often ask people, “What’s going on that is making you feel suicidal?” and most of the time, there is a reason, whether they actually tell me the reason or not. The perceived inability to change an outcome or a “feared” outcome is usually the most significant precursor to suicide becoming an option in a person’s mind. Mental pain can rival any physical pain out there and that needs to be acknowledged with any person who suffers from depression. I often tell people to think of the worst-case scenario, or the fruition of what they fear the most and to prepare for it… not to ruminate on the happening, but to accept the fact that it can happen (no matter how far-fetched the fear…telling them that their fear is illogical usually doesn’t help much… and it is very difficult to convince someone who has experienced “the worst thing” happening, that it can not happen again… it can). Once they prepare for the worst, and know their course of action, they should put it away… write it down… what will they do if x, y, or z happens. Then do whatever it is that they need to do to get through in the meantime, watch positive tv, escape in a book, clean things up… live life as close to as “right” as possible so as to not compound the problem. Above all, let go of the past and mistakes. We all make them, every last one of us. We can not change the past, we can only control our present and future and go easy on ourselves, the rest of the world judges us enough, we don’t need to compound it by ruminating and self flagellation.

  • Julia

    Thanks, Sherri! I suffer from anxiety and the advice you give to depressed patients is helpful for me as well. I truly believe that thoughts change chemistry and I struggle to change my anxious thoughts. Medication has never helped me. Just deep breathing, exercise and tapping. I will try your technique for dealing with FEAR because that’s where I dwell, especially since my cancer diagnosis in 2008. Thanks again for your helpful advice!

  • Malachy Grange

    Sheri,
    Thanks for your thoughts. Certainly reframing our thinking can help alleviate some depression. It scares me though to think you are giving this advice to people you do not know who may be suicidal. Many people suffer from “brain soup” depression and no amount of cognitive, existential or spiritual interventions will help. They need the right meds, which unfortunately, are often a hit or miss proposition at first. Using only the methods you describe, without medical help, may actually worsen the situation, and lead sufferers, paradoxically, to believe it is their fault. Be careful and wise in your comments to those on the edge.
    Thanks

  • Karen

    I read your insightful post and it pieced so much together for me. I too struggled with generalized anxiety disorder and could not stop the whirl of thoughts ruminating around in my head. I wish I had sought the help of my psychiatrist sooner because I had learned so many coping strategies but they were locking me inside my depression. My inability to solve problems and not wanting others to see what was inside my thoughts only added more fuel to the depression. So I have learned cognitive behaviour therapy which has helped with my thought processes but it was difficult for me. I had a lot of”‘unthinking” to do and I was majorly depressed when I finally sought help so my inability to master CBT somehow caused me to feel like I was more isolated from the human race because I thought irrationally.

    As your article has suggested, depression really plays with one’s mind. One of the really helpful tools for me has been mindfulness and acceptance and this has lead me out of the darkness and I am now seeing the light.

    I am on antidepressants and I most probably will be for a long time as I have had too many setbacks now, but I believe they help to take the edge off the depression so that I can work on challenging my thoughts. The inability to solve ones problems was always a problem for me but mostly due to not being able to communicate well. So I now deal with the problems I can solve and accept the ones that I can’t. I too separate the two. I no longer accept other people’s problems as my own am slowly setting myself free.

    I was interested in this article because there have been times where I have been unable to find the thought that has lead to my depression and I have had the discussion with my psychiatrist who reiterates that the thought might be ongoing. I usually do find it and challenge it.

    Routine is what works for me. As you have mentioned do what works for you to push past the depression then you can put all the other strategies in place. For me I list three things that I would like to achieve by the end of the day. These can be small when really low or substantial when not so bad. It is the sense of achievement that leads me to feel in control of my life and not helpless at all

    Thank you so much for this post Alex, it has really helped.

    Karen: I’m so glad you found the post helpful.

    Alex

  • shadow

    Dear Alex,

    Thanks for this site.

    I have been depressed for almost 8 years now, and despite some medical/therapeutic help, I don’t see much of a way out. You correctly describe the state of depression as fortifying itself. Another aspect to this, however, is that talking about it with friends and family reinforces it, too, at least after some time. Whenever you say something or do something with people who care about you, they check on whether you are in a suicidal state.

    This is one reason I stopped talking about it. While it is very comforting to know people actually still care about you, you just can’t stand the fact that you’re almost equated with your illness. This is especially severe if you’re an energetic and social guy like me, whose real self is so distant from one’s “depressed self” such that good friends easily spot the difference.

    Shadow: So true, what you say, that we often conform to the images we’ve long ago planted in the minds of our friends. Makes recovering from things like depression even more challenging.

    Alex

  • [...] a previous post, The True Cause Of Depression, I discussed how having multiple problems at once seems to cause more stress than having only one [...]

  • Jim

    Since first reading A Letter to a Widow on the Tiny Buddha website, I have been a real fan of yours. However, I was a bit upset that you would suggest using electroconvulsive therapy given all the negative assessments I have read, including short term memory loss, that it doesn’t last very long (relapses are common) and that it has other long-lasting negative (devastating?) effects.

    Jim: Like all therapies, ECT has potential side effects. However, in the right patients—for example, those who are so severely depressed they’re catatonic and for whom no other therapy has worked—it can be life-saving. Though relapse is common, for acute depression, no therapy is better.

    Alex

  • Paula

    In response to Jim, who had issue with ECT. I too have a problem with the use of ECT. I’ve talked to people who say that it really helped them. However, I’ve never heard how they felt a year later. As an adolescent in the early 70′s I was struggling with depression and had begun running away from home, using illicit substances, etc. Because my family had good health insurance, some professional along the way referred my parents to a psychiatrist who recommended ECT. Now, they didn’t try an antidepressant, nor did they try a therapist. They just had me hospitalized for a couple weeks. I received several shock treatments. First, one every other day, then twice a week and so on. I was allowed to go home and return on outpatient to have more shock treatments at about one every two to three weeks until my insurance ran out. Well, I tell you, before they gave me a treatment, they put a rubber thing in my mouth to keep me from breaking my teeth… Then they gave me a shot that caused me to feel like I was suffocating. I was told it included a muscle relaxer and another agent that I can’t really recall. Ha, it’s a wonder I recall anything. Anyway, this feeling only lasted a few seconds before I went to sleep, but I had this weird sensation all over my body. This suffocating feeling was very scary. Really, too scary for a 13-year-old girl. I begged my parents to get me out of that hospital… I begged them to stop the treatments, to no avail. They were convinced that this was going to help me. Later, I developed nightmares about it. I’d be running from these people in lab coats… It was like a horror movie in my dreams. Now, I don’t have the nightmares. I’m ok. But, it really did a number on my willingness to trust my parents. I still have bouts of depression, but thanks to SSRIs I cope quite well. Just wanted to say I think ECT is outdated. And, there’s an easier way to change someone’s brain chemistry.

    Paula: It sounds like you had a horrific experience. ECT is rarely now used as a first-line therapy, except in patients so depressed they’re catatonic. However, I would caution you, and my readers, about drawing broad conclusions about the effectiveness and safety of any treatment from anecdotes. I’m not trying to come across as a hard-line champion of ECT. But it does have its place in the treatment of depression. As with all therapies, you have to choose the patients carefully.

    Alex

  • Linnie Bird

    Thank you so much. So—my lifetime of depression was caused by my absolute powerlessness as a child. Ahhh—now I understand why it was so hard to “be.” Still working on it, but this simple truth has opened for me a huge door.

    Once again, thank you.

  • Julia

    On a practical note I read an article about genetic research done at Johns Hopkins that shows which depressed patients will benefit from taking SSRIs, and which ones won’t. Patients who won’t be helped can avoid the 3-month wait period and side effects of the pills while pursuing other options. Does anyone else know more about this research? Is it out of clinical trials?

  • Malachy Grange

    Once again, I caution those describing depression as existental, attitudinal or a response to childhood trauma to realize that broadcasting these ideas may put many at risk for suicide who absolutely need chemical treatment. No doubt, there are those who will benefit from professional or personal resources whose depression stem from circumstances and thinking skills, but some may think using anti-depressants the way of “weakness” or not facing problems. This can be absolutely untrue, and some may delay or refuse to consider the “brain soup” therapies that have become more accurate and effective. We should be mindful how we describe and counsel those with depression symptoms.

  • Julia

    I’m not categorical opposed to medications and have myself taken anti-anxiety drugs while undergoing treatment for cancer. I do think SSRIs can be over prescribed. For example, the new PDR says patients who mourn the death of a loved one should be treated with anti-depressants if they aren’t better in TWO weeks? That’s extreme. What I support is individual *targeted* therapies. Why not at least use available technology to test drugs on patients before prescribing?

  • Jim

    Of course SSRIs are oversubscribed and often unnecessary and the PDR recommending anti-depressants for mourners “who aren’t better” in two weeks is unconscionable and absurd.

  • Zigy

    Alex, again jumping here as I delight in catching up with all your wisdom (and experience, at least in this post).

    You wrote:

    “I would hypothesize that in most cases depression arises at its core from a belief that we’re powerless to solve our problems.”

    One of the reasons I chose my psychotherapeutic practice is because of my own almost-lifelong depression (and the insight it gives me for my clients), and as I continue to do my own work, I have come to recognize exactly what you wrote above: I have always believed that I was powerless. Only now have I come to that long-delayed but critical awareness and am astonished at the difference it has created in my daily personal life.

    Without joining the mind/body-endogenous/exogenous debate, there is no doubt in my mind that the clients I see with the most profound struggles often have at their core that dreadful and debilitating belief.

    Thanks again for your service.

    z

    Zigy: I’m glad this resonated with you. I’ve actually developed my thoughts on this a little further and will be writing about it more in my next book.

    Alex

  • Jim

    Yes, I agree 100% with Ziggy: the sense of powerlessness (I can’t beat this, I can’t overcome that) is at the core of being depressed. Armed with a sense of having the ability to solve problems that lead to depression, no depression has a chance of surviving. Believe (ala Buddhism) that you are OK and the fears that accompany depression (they always do) will wither away. Just a novice here, but I think it makes far too much sense. You have to believe good things that will then lead to good things (yep, sometimes superhard), but as Richard Bach said, “Argue for you limitations, and sure enough, they’re yours.” I look forward to Alex addressing this important and life-altering issue in his next book.

  • […] friend or family member to suicide, I have lost a patient (who I wrote about in a previous post, The True Cause Of Depression). I have known a number of people left behind by the suicide of people close to them, however. […]

  • Scott

    If you really want to know the true cause of depression, you need to ask the patients. We all get depressed for our own reasons. Depression is not some type of plague. It’s an emotion and a natural one at that. If a loved one dies, do we not feel sad? If a baby laughs, do we not feel happy? Our brain chemicals work, and they work like there suppose to. Depression is commonly a reaction to a circumstance or experience one has, just like feeling happy is a reaction to its own.

    I do agree it usually involves a person believing they are powerless and that thoughts are influenced by such depressed feelings which keeps the downward cycle going. I think the medical industry wants people to believe depression is a medical issue; however there is no proof, the only test is a written questionnaire. We’re not born depressed, we get depressed. It’s a feeling, a mood, a state of mind. I have years of battling this feeling called depression and know it inside & out. I challenge any medical doctor in this subject.

  • Malachy Grange

    Scott, you should speak for yourself and not everyone else…yes, anti-depressants are over-prescribed and depression misdiagnosed. There are better ways to deal with this kind of depression: exercise, diet, social support, counseling, re-framing attitudes and beliefs, meditation and prayer, etc.

    But many of us do have “brain soup” depression, and we need the right antidepressant(s) to get symptom relief. Circumstances, attitudes, existential dilemmas have nothing to do with our kind of depression. It starts with a biochemical imbalance that produces physical symptoms, the actual slowing or depressing of our nervous system. If you have never experienced this, you really cannot understand it. In time, untreated depression of this kind can lead to thought and emotion distortion which can lead to disability, suicidal thinking and unfortunately, suicide attempts. Getting the right medicine is crucial. Be careful of broadcasting your personal views as the truth for all.

  • Julia

    I would like to hear from those who have taken SSRIs purely for anxiety. Helpful or not? How does one know if cause is chemical or just normal response to unfortunate life circumstances? I’ve read that SSRIs can even trigger anxiety? Is there a nocebo effect if one takes an SSRI reluctantly with fear of side effects? I don’t doubt SSRIs help some, but who?

    Julia: SSRIs can indeed trigger the anxiety they’re used to treat, so you have to start at a low dose and increase slowly in anxious (as compared to depressed) patients. It’s really difficult, if not sometimes impossible, to tell if the cause of anxiety—or depression, for that matter—is caused by something “chemical” or a normal response to unfortunate life circumstance. Coincidentally, I’m writing about this in my next book.

    Alex

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