Category: Depression

Depression-Mild vs. Moderate

In my last post on depression, I stressed the key points differentiating a bipolar disorder from a depression.  In this post, I will focus on the differences between mild and moderate symptom profiles, as well as normal mood swings and a Major Depression.

Moderate to severe Major Depressions are easy to differentiate from normal mood swings.  The significant difference is titled “vegetative symptoms.”  This may call to mind comatose people or someone drooling in a corner; however, the meaning is different.  Vegetative symptoms of a depression are the physical symptoms that emerge when one declines from a mild to moderate level of depression.  This is the stage where people seek treatment, or are pressured by others to do so.  Please keep in mind that the diagnostic rules of Major Depression only differentiate mild from moderate levels of severity based on functional impairment.  My contention is that this functional impairment is a direct consequence of the physical symptoms of depression.  Often the physical symptoms are so unexpected and alarming that many people believe it is another disorder entirely.

The vegetative symptoms of depression occur in polar extremes; sleep is minimal or too much,  appetite is reduced or hunger excessive, energy is decreased or a constant agitated fatigue sets in.  It is difficult for people to believe that a psychological problem could cause such physical disruption.  Often those who complain of chronic fatigue or general malaise are clinically depressed.  Most people expect a depressed person to be very sad and tearful, but a moderate Major Depressive may not have a subjective (personal) sense of sadness, nor may they be tearful.  Chronic irritation and general fatigue are often presenting complaints of the chronically depressed.  Men are more apt to experience irritation/anger as the prominent feature of depression than women.  In the mild phase of depression, a person may be aware of a lowered frustration tolerance, but it is able to be controlled.  The moderate stage may reveal rage reactions or simple frustrations that quickly spin out of their control.
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Sleep disruption is almost always an important factor in moderate Major Depressions.  Few people perceive increased sleep as a problem, yet the increased sleep engendered with a depression doesn’t increase sleep comfortably or effectively.  The increased sleep tends to be debilitating.  Please note that sleep may be reduced in a Major Depression, but I am focusing on the increased pole, at the moment.  Missing work, missed children appointments and missing one’s own appointments are more common than not.  Getting out of bed and into the washroom may feel to the afflicted like an epic journey.  For example, the daughter of a close friend became moderately depressed.  Her nine year old daughter came home each day from school to find her mother in bed.  She no longer makes her daughter meals or takes her to school.  Increasingly, the daughter takes care of her mother.  This dynamic is often observed in families with substance abuse; the course of the treatment is different, but the danger to the family is similar.

As most of us wish for more sleep, we also desire less appetite for food.  Supposedly, in excess of a trillion dollars is spent on global weight loss strategies annually.  Weight loss secondary to depression is effective, though drastic, unpleasant and unhealthy.  The loss of appetite from depression is often gradual, such that it’s cause is obscured over time.  Often the sight and especially odors of food will make one feel nauseous.  A useful clinical rule is that a ten percent drop in total body weight in one month spells medical trouble.  As with sleep, please note that that appetite may also be increased by a Major Depression, but I am focusing on the decreased pole at the moment.  Women are more apt than men to be pleased with the weight loss-initially.  Others typically remark about the unhealthy appearance of this type of weight loss, decreasing the expected pleasure of hearing peers rave about the missing pounds.  This depressive weight loss also entails lower strength and energy, as well as lowered attentional resources.  There is little comfort or complements to be gained from depressive weight loss.  As with reduced sleep, medications to treat the symptoms tend to prolong or exacerbate the problems.  The only known way to combat the sleep and appetite disruption from  depression is to treat the underlying depression.  Please leave comments regarding this post in the space provided below.

Grief

Grief is not considered a mental disorder.  It is not even listed by its own name, but goes under the title of “bereavement” in the DSM-IV.  Most English speakers will typically use the term of “grief” to describe their emotional reaction after the death or separation from a significant other.  The mental and physical symptoms are not readily distinguishable from a Major Depression or an Adjustment Disorder.  About 30% of grief reactions meet the criteria of a Major Depression, and about 10% have psychotic symptoms.

Professionals do not regard grief as abnormal if the worst of the suffering is over by 6 months; a year at the longest.  Death from suicide or a medical illness is increased significantly during the grief reaction.  The immune system is depressed, cortisol levels increase, and there is an increased risk of heart disease and cancerous malignancy during the course of a grief reaction.

Most mental health clinicians will not diagnose grief or bereavement before six months from the time of the loss, though the DSM IV gives 2 months as the guideline.  It is normal to have thoughts about actions one might have taken to save their life or keep the person as an intimate attachment.  Grieving individuals often feel as if they should have died, instead of their significant other.  They typically feel worthless, and experience a profound slowing of thoughts and actions.  There is often impairment in social and occupational functioning for several months.  It is even common to hear the voice of, or see a fleeting image of, the lost significant other.

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It is not the intensity of suffering, but the duration and quality of the suffering that differentiates depression from grief.  Visual and auditory hallucinations are common in grieving, but considered abnormal if they persist longer than 6 months.  Additionally, the hallucinations of a grieving person are always associated with the missing object; never with someone physically present or personally unknown to the bereaved.  For example, if a person experiences hallucinations of their dead father, after the death of their mother, and a voice tells them to kill their brother, this is less grief than a psychotic disorder.  Expressions of worthlessness and regret are directly connected to the missing object; otherwise the grief is likely part of a chronic mental illness.  Thoughts of death are focused on the missing object.  Desiring to die in the place of the deceased, or feeling that life is not worth living without their significant other, is expected and considered normal.  Harboring a plan to commit suicide unrelated to the missing object is severe Major Depression.

I hope this article clears up some of the confusion between normal grief or bereavement at the loss of a significant other, and the more unrelenting chronic forms of mental illness.  Many people are surprised to learn the level of suffering mental health professionals consider normal in the bereaved individual.  They are also surprised that auditory and visual hallucinations of the lost object are common and considered to be within normal limits.  As professionals do not recommend treatment for normal bereavement, family and friends of the grief stricken play an invaluable role.  Mental health professionals may be consulted if the condition fails to lessen, or even becomes increasingly severe.  Most importantly, do not criticize their emotional reactions to the loss.  It is best to be a kind and patient listener, rather than an ersatz psychologist.  Encourage the mourner to talk at their own pace and rate.  Encourage the bereaved to participate in life without being pushy or critical.  Also pay special attention to important dates in the relationship between the bereaved and the lost object.  Mourners may have worked through most of their grief, but find themselves falling to pieces during times when they would have been together; e.g., the Christmas holidays, birthdays, etc.  Please leave comments about this article on grief in the space provided below.