Have you ever wondered if multiple episodes of depression change you so much that you’ll never get back to your old self? Most people I hear from say: I want to be myself again. That’s their definition of recovery. Can it happen?
I found an interesting discussion about long-term changes in an online journal called Medicographia. The editors posed a question to psychiatrists and researchers from around the world and printed their responses together.
Here’s the question: Is the patient really the same after a major depressive episode?
The experts cover a lot of ideas, and I can’t summarize them all. But here’s an overview of their findings. Most of them believe that you’ll never be quite the same again.
Naturally, some people do better than others. Many cope well with depression, avoid negative thinking and can spring back from the illness. They’ve got good resilience. If that picture fits you, there’s more good news.
If you’re in great shape after an episode of major depression, meaning full remission of all symptoms, it will probably be a long time before you have another episode. You may even be done with depression for good.
Even if you do get another episode or a whole series of them, you’re more likely to get back your full health in between each period of depression. More depression is not a happy prospect, but being totally yourself after each episode is about as good as it gets.
Others don’t do so well. (I wish I didn’t always fit into this unlucky “others” category.) They have repeated episodes that cause long-term biological and psychological changes. Those changes lower your threshold for getting depressed the next time around.
Any residual symptoms after you’ve “recovered” mean you’ll likely have a much shorter break before depression strikes again than the folks who get rid of all their symptoms.
There’s a big problem, however, in figuring out whether you’re symptom-free or not. A physician who’s treating you, whether psychiatrist or primary care doctor, usually doesn’t measure your response to treatment with a formal rating scale, such as researchers use.
Your doctor wants to know how you’re doing with the major symptoms you’ve been most concerned about. If those are going away, you’ve “responded” to treatment. In other words, there’s been a reduction in symptoms. Great. You’re both feeling good about the outcome.
But there could be other symptoms you haven’t mentioned because they didn’t bother you so much – or perhaps you never connected them with depression.
Research is showing that there are many differences among people who are considered to be in remission. To measure these differences, they use to a formal rating scale, consisting of a series of questions about the severity and frequency of symptoms. The Hamilton scale is the most widely used. It assigns points for each answer, and an arbitrary lower limit has been set as the boundary between full remission and illness. However, that boundary isn’t 0. It’s 7.
Many “remitters” have mild symptoms ( with a score of 3-7) and face a much greater possibility of having a recurrence than full remitters (0-2). Apparently, even mild remaining symptoms predict more rapid relapse. So medical professionals are now urged to keep treatment going until every symptom is gone.
The changes depression brings with it can reach into many dimensions of your life: biological, psychological and social.
Family: Depression is an illness that affects the whole family. In the midst of an episode, you may have a lot of conflict in your closest relationships and try to isolate yourself from the people who need you the most. The damage doesn’t disappear overnight after you’ve started feeling better. If depression has continued for some time, or you’ve been through many recurrences, your family, especially your partner, can begin to get depressed as well. These are long-term wounds that take time to heal.
Work: Depression can affect the way others think about and behave toward you, especially at work. They may regard you as unstable or unreliable and be reluctant to entrust new projects to you. Stigma can affect your attitude toward yourself as well. It’s easy to internalize an opinion that you’re diminished by the illness or that you should have been able to handle it better.
Fear: After you’ve been through a serious depressive episode and lived with its disabling effects, you don’t want to go through it again. You may feel a lot of anxiety and fear about recurrence. Everyone wants to avoid a return of the illness and usually follows a treatment path to prevent it from happening.
Some people also get very cautious about avoiding stressful conditions that might trigger a new episode. That’s understandable and often necessary. But it can be hard to find a balance between realistic assessment of the risks you face and acting out of fear and anxiety.
The risk of recurrence is all too real, so following the treatment you’ve chosen and adapting your life style to stay as healthy as possible are wise and necessary strategies. At the same time, though, there’s a danger of underestimating what you can do and avoiding taking action that could turn out to strengthen your sense of self and level of resilience.
I’ve had a long fight with this sort of caution, fear and avoidance. Living with them has been a significant psychological change that has often blocked me from testing myself to see exactly what I can accomplish. I think of it as one of those scars of depression that needs its own therapy.
Memory: Researchers describe a couple of long-term changes in memory brought on by recurrent depression, and sometimes by single, prolonged episodes. Memory changes have a lot to do with brain biology, but living with the effects can bring on major psychological changes as well.
One is difficulty holding onto short-term memories. I’ve had a steady worsening in the ability to retain things people tell me as part of daily living. It’s a problem that also affected my work, which required me to track and summarize complicated discussions in large groups. This is a common effect of depression, but unfortunately it can continue after a depressive episode is over.
One of the researchers in the symposium brought out another aspect of memory I hadn’t thought much about. Instead of emphasizing memory loss, he points out that depression is an intense experience that can etch some memories in great detail for permanent storage.
These are the memories of emotionally and negatively charged experiences that occur during depressive episodes. As this researcher puts it, memory is a way of prolonging the past. Through vivid memories of negative experience, depression keeps up its influence long after an episode is over. Those memories can overshadow new incidents and cause them to be interpreted negatively as well. These memories contribute to a recurring cycle of depressive ideas about yourself and make you more vulnerable to a new episode.
Social and psychological changes may be bad, but at least you can work on them in therapy and support groups. Biological changes are completely beyond your ability to control. Hopefully, medications will eventually help correct them, but right now the changes themselves and their relationship to depression aren’t clear enough to lead to specific biological treatment.
The best documented change has to do with brain anatomy. The size of the hippocampus, an area linked to memory formation among other things, is smaller in people who’ve lived with depression – the longer the depression, the smaller the hippocampus.
This could be related to a reduction in the level of BDNF, a protein which is crucial in the formation of new neurons. As BDNF decreases neuron cells lose the support they need to survive. BDNF is active in the hippocampus, among other areas of the brain, and a decrease in its availability may be one of the causes of its reduction in size. Depression also relates to higher levels of stress hormones that can have a variety of destructive impacts. More familiar from all the publicity surrounding antidepressants is the effect that the illness is thought to have on neurotransmitters. Reductions in the levels of serotonin and norepinephrine, in particular, have long been associated with depressive symptoms.
The connections among these and many other biological processes and their relationship to depression are still under study. But the biological dimension of depression seems to have long-term consequences on brain functions and may make each of us more vulnerable to recurrence of the illness.
What Can Be Done?
Given the breadth of potentially long-term, even permanent changes, how effective are current therapies in dealing with them?
The consensus of the researchers seems to favor the use of varied treatments to manage each type of change. They recommend a holistic approach instead of total reliance on antidepressant medication.
The next post will explore the brighter side of treatment. As more is known about how antidepressants actually work, it appears that they may counteract some of the major biological changes caused by depression. A variety of psychotherapies can also help deal with the psychological and social changes that untreated depression can inflict.
So there may be hope that you can be yourself again, though perhaps showing some wear-and-tear.
What long-term changes have you observed in your life as a result of depression?