Richard A. Friedman is professor of clinical psychiatry and director of the Psychopharmacology Clinic at Weill Cornell Medical College.
For months he had thought that his symptoms were nothing more than an expected response to his financial burden that he had to power through. But after his wife insisted he needed help, he consulted me. What scared him was that he had started to think that he was a drag and that his family would be better off without him.
My patient was actually suffering from clinical depression, but his belief that his distress was just “normal” anxiety, is very common. To say that we live in stressful times is an understatement. Covid. The climate crisis. A country riven with tension and political discord. What’s clear is that the world we live in has taken a toll on our collective mental health. Survey after survey tells us that we are stressed and that rates of depression and anxiety have skyrocketed.
Between 2019 and 2022, the rates of anxiety symptoms in adults jumped from 8 percent to 29 percent, and the rates of depressive symptoms rose from 7 percent to 23 percent, according to the Household Pulse Survey conducted by the National Center for Health Statistics in partnership with the Centers for Disease Control and Prevention. Some of the steepest increases were seen in males, young adults, Asian Americans and parents with children at home.
A quick look in our medicine cabinets is another gauge of our distress. In 2019, the CDC estimated that 15.8 percent of Americans were taking a medication for mental health; as of July, 25 percent of us are.
These are snapshot studies, and it’s too soon to know if this spike in depressive and anxiety symptoms will translate into a wave of serious clinical depression and anxiety disorders. But it is never too soon for people to wonder whether they are just stressed and sad — or clinically depressed.
Feeling sad is normal, but depression is not
It’s a critically important distinction. Feeling distressed and sad is a normal and expected response to what we’ve endured these past several years, including the social isolation and loss of human life brought about by the pandemic. It would be remarkable if we didn’t feel worried, anxious or sad given what we’ve experienced.
But unlike everyday sadness, clinical depression is never a normal response to stress or trauma; it’s a serious medical illness that is associated with significant impairment in our ability to function in major areas of our life — in relationships, at home and at work.
Major depression is common, affecting 17 percent of Americans in their lifetime, and it is a leading risk factor for suicide. It is estimated that 2 to 15 percent of people suffering from depression will die by suicide. (This broad range reflects the fact that depression runs the gamut from very mild to very severe, and suicide risk increases with severity of the illness.)
So how can you tell if you are depressed or just plain sad?
To start, depression is a syndrome that involves far more than sadness. Aside from a sad or flat mood, depression typically causes insomnia, loss of libido and appetite, social withdrawal, low energy, feelings of hopelessness and suicidal thoughts, feelings and actions.
Sad people are unhappy about a specific event, while depressed people feel bad about themselves and have a loss of self-confidence.
If you’re not sure, ask yourself just two questions: how often in the past few weeks have you lost interest and pleasure in doing things? How often have you felt down or hopeless? You can check your score on this Patient Health Questionnaire. If your score is 3 or higher, there’s a high probability that you are depressed, not merely upset.
Depression is a medical illness
You might question whether depression is a medical illness in the same way hypertension or diabetes are. But you shouldn’t. There is abundant scientific evidence that clinical depression is associated with distinct brain changes in circuits that regulate mood, sleep, energy and appetite.
Brain-imaging studies have identified multiple regions where there is altered activity or structure in people with depression. For example, in those with more severe depression, there is a reduction in the size of the hippocampus, a brain area critical to learning and memory. The longer and more severe the depression, the greater the hippocampal shrinkage.
The notion that depression results from a chemical imbalance of any neurotransmitter such as serotonin is simplistic and wrong. We know this, in part, because SSRI antidepressants such as Prozac and Zoloft increase serotonin in the brain within hours — but generally take several weeks before they alleviate the symptoms of depression. If depression were caused by a deficit of serotonin, you’d feel better in a day or so after taking an SSRI.
Depression isn’t a disease of a single neurotransmitter or brain circuit, but more likely a system-level disorder involving multiple pathways and their related neurotransmitters. For example, we know that after several weeks, SSRIs increase the level of a brain-derived neurotropic factor (BDNF), which promotes neuronal growth and connection, and this timing corresponds with its antidepressant effect.
We don’t yet understand what causes the biological abnormalities in depression to come about in the first place, but we think it results from a complex interaction between genes and environmental stress. Still, we know a lot about how to treat depression. Both psychotherapy and antidepressants are highly effective for depression. Brief psychotherapies such as cognitive behavior therapy (CBT) and interpersonal therapy (IPT) are empirically proven treatments for depression. CBT helps people identify the mistaken and distorted thoughts caused by depression and then challenges and corrects them, thereby lowering distress. And IPT focuses on restoring interpersonal relationships that are disrupted by depression.
Therapy and antidepressants are most effective
Psychotherapy is a first-line treatment for people with mild to moderate depression, but when depression is severe, meaning either the presence of psychotic symptoms or suicidal thoughts and feelings, then a combination of therapy and antidepressant medication is the safest and most effective approach.
Antidepressants are not a treatment for everyday unhappiness or distress. Unless you have a form of clinical depression with its associated biological changes, antidepressants will not make you happier. The misuse of antidepressants to treat normal distress would be akin to using an antibiotic to treat the common cold, which is caused by a virus and not susceptible to an antibiotic.
Exercise also has significant antidepressant effects, aside from increasing energy and making you physically fit. In addition to the well-known release of endorphins, increasing your cardiac output with exercise triggers the release of BDNF, something exercise shares with SSRI antidepressants.
Social connections, often disrupted by depression, are critical to treating depression. I urge patients to maintain contact with friends and family because we are social animals and feel comforted and supported by loved ones.
In addition to medication, brain stimulation therapies such as electroconvulsive therapy (ECT) and, more recently, transcranial magnetic stimulation are very effective in treating depression.
There are promising new drugs for depression such as ketamine, esketamine and psilocybin, which produce rapid and enduring antidepressant effects within minutes to hours of administration. These drugs also produce rapid neuroplastic effects and, in a sense, “rewire” the brain.
My patient was surprised — and relieved — when I explained that he was suffering from major depression and not everyday sadness and anxiety. I started him on an SSRI antidepressant and saw him for weekly supportive therapy. His sleep and appetite improved within the first week, and by the end of three weeks, his sense of dread and catastrophic thinking were gone. “I am reacting to stress like my old self,” he said. “No more gloom and doom.”
Everyday sadness is universal and passes by itself. But depression is a potentially serious and highly treatable illness that no one should confuse with being sad.
People often blame their depressed mood on some disturbing aspect of the world, such as the state of the economy or politics. Another patient of mine insisted he was anxious and depressed because of the negative impact of the economy on his business. After successful treatment, however, he said, “the world is the same, but my reaction to it has changed. I thought the sky was falling and now know that was wrong.”
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