Psychiatrist talks about causes of depression and what is it like to live with it

People, who enter a depressive state after experiencing trauma, usually have acute symptoms of depression, but there are others with a chronic condition or dysthymia that they may have learnt to live with. The second kind makes it difficult for people to experience pleasure or joy in life and can be harder to identify and treat, says Mumbai-based psychiatrist Dr. Gaurav Kulkarni. 

According to the World Health Organisation (WHO), depression impacts more than 264 million people globally. “Depression is different from usual mood fluctuations and short-lived emotional responses to challenges in everyday life. Especially when long-lasting and with moderate or severe intensity, depression may become a serious health condition. It can cause the affected person to suffer greatly and function poorly at work, at school and in the family,” says the organisation.

According to a study published in the Lancet journal, in 2017, 197·3 million people suffered from mental disorders in India; this includes 45·7 million with depressive disorders and 44·9 million with anxiety disorders.

In this part of our series of interviews on depression, Dr. Kulkarni talks about Dysthymia, causes of depression, and more. Edited excerpts:

What is it like to live with depression? Are there different stages or levels of depression that people experience differently?

There is a single clinical terminology of depression but there are different levels that can be differently classified. If someone has acute depression, which can be a reaction to a catastrophic event, their depressive symptoms are different compared to somebody who has been going through a constant nagging difficulty in their life, possibly for years. Chronic depression can result from financial difficulty, domestic abuse, or substance use, something which has been there for years and a person has learnt to live with it. At the mood level, they are constantly unhappy or sad. When we diagnose someone with depression, we try to identify whether a person has acute symptoms or has their condition been chronic.

If someone has acute depression, which can be a reaction to a catastrophic event, their depressive symptoms are different compared to somebody who has been going through a constant nagging difficulty in their life for years together. Chronic depression can be from financial difficulty, domestic abuse, or substance use, something which has been there for years and a person has learnt to live with it. At the mood level, they are constantly unhappy or sad.

In cases of people with acute symptoms, they have usually entered a depressive state after some kind of trauma in their life. We see almost all of the depressive symptoms in them. They feel absolutely miserable and they are not able to live their life the way they should.

But the other kind of patient may be someone who has been a victim of domestic abuse, who has been going through it for a long time and has learnt to live with it. At some point of time she’s sitting across from a therapist or a psychiatrist and she does not say that she is depressed. In these cases, the psychiatrist or therapist can identify depressive symptoms. The kind of depression that people often learn to live with is called dysthymia or persistent depressive disorder.

Dysthymia requires intervention. Dysthymia requires intervention. In dysthymia, we may not see typical symptoms; we may see a lack of interest in life, an inability to experience pleasure or joy, a negative view of the future, significantly traumatised self confidence, and an inability to do anything for self or for others. It is almost like being a slave of depression. These people have come to terms with the fact that they have to live their life with restrictions. This significantly affects their happiness.

Dysthymia requires intervention. In dysthymia, we may not see typical symptoms; we may see a lack of interest in life, an inability to experience pleasure or joy, a negative view of the future, significantly traumatised self confidence, and an inability to do anything for self or for others.

When we are not able to identify any acute stressors, we need to identify whether the depression has been ongoing for years. People with dysthymia have learned to live with it, they are compromising on the quality of their life, interpersonal relationships, and on productivity.

So, depression can be latent?

We see so many people where they have almost never identified their difficulty as the mental illness. For them it has almost become a normal part of life; they may cry twice or thrice a week because they are not happy, but they are not able to understand that not being able to feel happy is a symptom of depression. Some of them can just remain latent and unidentified by others or even by self.

We see so many people where they have almost never identified their difficulty as the mental illness. For them it has almost become a normal part of life; they may cry twice or thrice a week because they are not happy, but they are not able to understand that not being able to feel happy is a symptom of depression.

When any mental health issue starts becoming a chronic issue, helping that individual and treating that chronic issue can become a challenge. That person almost internalises certain symptoms and feels that this is how life is going to be, helping those people can sometimes become a big challenge. But it is absolutely a myth that depression cannot be treated, it absolutely can be treated. And going back to that premorbid functioning, physically, mentally, emotionally is absolutely possible.

It is absolutely a myth that depression cannot be treated, it absolutely can be treated. And going back to that premorbid functioning, physically, mentally, emotionally is absolutely possible.

What causes depression? Is it genetic? How much of it is related to childhood trauma or the environment someone grew up in?

All mental health issues have three significant contributors — biological, psychological, and social. Everything which is more bio-psycho-social in its makeup is can be a cause of mental illness.

There is a strong genetic inheritance for almost all mental health issues, whether it’s depression, anxiety, OCD, bipolar disorder, or schizophrenia. If a family member has the genetic morbidity, there is a very high chance that the gene will be passed on to the next generation. It does not mean that if the gene is passed on to someone, they will definitely experience depression.

This is where the next part comes in. If someone is biologically predisposed, if someone has inherited these genes, the person has a higher chance of issues with their neurochemical function, maybe some dopamine dysfunction or serotonin dysfunction. But at the same time, how much of this gene will be expressed in a wrong psychological environment is what is important. If someone is going through psychological trauma or experiencing negative life events, if their life is riddled with stress, emotional issues, or bullying, the chances of their vulnerability to get expressive is always a bit higher. With psychological trauma, a person’s ability to cope with stress, their ability to rationalise their life, to think another way, starts getting affected.

The social concept is everything around a person that supports them and that can be a causative agent. Something like major financial loss, loss of a partner, loss of a spouse, any traumatic event can trigger it. In a lot of patients depression happens only because of a change in residence, the change in the country, the other factors remain the same, the biology is the same, their psychology is the same, but because their support system has modified, they tend to move into the depressive zone.

Covid has been a great example for all of us as psychiatrists and therapists. This has been the first time that we have seen a strong, high magnitude, social stressor like a pandemic, which none of us have ever experienced in life, affecting people’s mental stability. This is a classic example for all of us that even though someone is emotionally strong, even though they are biologically not vulnerable, just the social changes, being quarantined in a room, can affect their well being. Biology, psychology, and sociology, all of them are responsible for mental illness. And even in treatment, we believe that we should try and achieve a more holistic approach where you are able to achieve a balance between all three. That is when you are going to see the best improvement.

---

You may also like: