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Tuesday 2 August 2011

Multistrand Depression

Like most psychological disorders, major depression is diagnosed with a checklist of symptoms:  low mood, inability to enjoy former pleasures, fatigue, sleep disruption, difficulties with concentration and memory, and so on.

To this list we can add many symptoms that do not appear in the diagnostic criteria:  an aversion to light, a sense of being easily overwhelmed, a breakdown of automatic behaviour, social withdrawal, and more.

The reason we have a general label, depression, for all of these symptoms is that, although each can happen without the others, they often cluster together.   When you get a “lumpiness” of these symptoms – a number of the more critical ones happening at the same time – we assign the problem an overarching label:  Major depression.  

The moment we give this symptom cluster a name, it begins to seem like a real thing.  We say “Ah, I see your problem.  You have major depression.” And it sounds as though we have explained something and now understand it.  In fact, all we have done is provided a label.  

“I have these five symptoms.” 

“Oh, then you have five-symptom disease.”

Labeling a problem can actually be quite useful, particularly if it points the way toward a treatment plan.  This is less often the case in mental difficulties than in physical ones, but never mind. We practitioners still like sounding bright when we diagnose.

A down side of the label is that it unifies the symptoms into what now seems like a distinct entity. This leads clinician and sufferer into a set of presumptions about the problem, most of which are not helpful.  “One problem, one cause,” for example. 

And then there’s the issue that this post is really all about.  (How’s that for a long lead-in?)  As the depression fades, we tend to assume that all of the symptoms will go away at the same time.

This doesn’t happen.

Rather than seeing depression as a single rope of difficulty, it helps to see it as a multistrand entity.  Take the rope and unravel it.

As the problem itself begins to abate, the different strands begin moving upward (or downward, depending on how you think of such things) at different times.  Some symptoms tend to fade early, others lag.

So which symptoms tend to improve early, and which improve late?  I’m not aware of formal research into this question, though I suspect if I looked a little harder I might find some clues.

I’ve been treating depression for over 25 years now, and for much of that time it has been my primary focus. I try to be cautious about speaking on the basis of what has inevitably been a nonrandom sample observed using a fallible recording instrument (my mind). And in fact the moment anyone says “In my clinical experience…” it’s best to set one’s skepticism to HIGH.

Nevertheless, I think I’ve noticed some consistency as I’ve watched people get better.  First to improve is often the anhedonia – the inability to enjoy things. If we can get people to do at least some of the things they used to enjoy, faint flickers of their former enjoyment begin to return.  

The trick is to avoid dismissing these.  People will say “I used to LOVE doing this, now it just seems faintly amusing. What’s the point?”  The point is that this pale imitation of former passions is a sign of things likely to come. Keep doing those things, and branch out, doing a variety of them, and the volume control on the enjoyment tends to go up.

Eventually people will say that while they are in choir practice, or at the movies, or playing cards, or hiking they are just like their old selves.  But the moment they get home the mood plummets as low as it ever was.  Some would almost prefer not to be lifted up if they are just going to be dropped down again later, but I’m afraid that goes with the territory.

What improves last?

In my clinical experience (did you remember to become skeptical?), the cognitive symptoms – poor memory, concentration, decision making – often lag behind the rest.  

“It’s weird.  I feel mostly like my old self now, and I don’t seem to crash into the pit – not much, anyway – but I still can’t find my car keys, or remember people’s names, or decide what to have in a restaurant.”

Why is this?  I suspect that these cognitive skills are strongly based on practice. After a period of depression our ability to retrieve memories, decide between options, or focus for extended periods becomes, well, flabby.  It’s like a person who lies for weeks in a hospital bed recovering from pneumonia: afterward their muscles are weak.  The illness is over, but their strength is poor.  They need to spend some time building themselves back.

Practice may help – but before I write more on that topic I’d like to see if I can track down some work on cognitive rehabilitation after depression. Certainly it appears that my clients get all of their faculties back with practice and effort – though not necessarily with the simple passage of time.  Reading, puzzles, shopping, testing oneself (quick: who was at that dinner party last Wednesday?), sitting and quietly working on a mental task – all seem to help.

My overall point:  When we recover from depression, the label dissolves and the bundle of symptoms unravels. Some improve early, others late. If you get some signs of improvement but other symptoms persist, take heart: the early improvement likely signals more to come.  

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