The Quiet Crisis of Chronic Depression

Andrea Mantegna Presentation at the Temple (Detail)

Chronic depression, also known as dysthymia, is supposed to be a milder but longer lasting form of the illness than the more episodic and severe variety known as major depressive disorder. Yet I have come to believe that no form of diagnosable depression should be called “mild.”

My concern is not about the accuracy of these terms according to a standard measurement scale. I worry about the effect that words like “mild” and “moderate” have on people who are considering what to do about depression.

Years ago, when I was trying to ignore my problem, I liked to say that I had “minor” depression.

“Mild,” “moderate” and “minor” may not be the formal diagnostic terms, but they worked well in helping me downplay the illness and put it lower on the list of priorities for action. People devote themselves to solving big problems. No one has time for the little ones. I thought my depression was in the category of the little problems.

Major or Minor, Mild or Severe?

That bit of self-deception enabled me to sidestep the inconvenient truth that this “minor” condition had been with me since childhood and had played a part in undermining many aspects of my life. I chose to focus on the undeniably “major” depressive episodes as the real problem.

Those were the periods when I lost almost all motivation, energy, mental focus, ability to relate to people, and at times even the will to live. There was no denying that I could function only at a minimal level and that I needed help to get through the illness.

But when this acute phase ended, life rarely went back to normal. Because I had lived with depression for most of my life, I didn’t have a very good idea about “normal” anyway. To me, normal tended to be about 50% of the level of energy and drive that I needed to feel capable of doing everything I knew I could do.

Since I didn’t concern myself with “minor” depression, I never tried to learn much about its effects. Instead, I assumed that what it was doing to me was not the effect of an illness at all but simply a part of my personality, the given traits that made up my identity as a person.

I was willing to get treatment for the severe episodes, but the rest was just me. That’s what I thought back in the 1980s and early 90s before information about depression became so widely available.

Yet, today many people with chronic depression may believe the same thing and be slow to do anything about it. Perhaps they believe the condition is just the way they are.

Forms of Chronic Depression

Psychiatrists and researchers are learning that the distinction between episodic and chronic or between severe and mild breaks down if you look at the long-term course of depression. They’ve been adding types and subtypes of chronic depression, and the boundaries are overlapping more than ever.

Besides dysthymia, there are three other forms of depression that have the chronic label attached to them.

Double depression. This doesn’t seem to be a formal diagnosis, but it refers to the onset of a major depressive episode at least two years after the beginning of dysthymia. Most people with dysthymia also experience major depression at some point in their lives.

Chronic major depression. This refers to major depressive disorder that lasts for at least two years, and it happens to about 20% of people with this diagnosis.

Partial Recovery. The third form is also quite common. It’s an incomplete recovery from major depression in which you may get well enough to stop qualifying for the formal diagnosis, but you are still beset with many of the symptoms.

I have lived with all four forms of chronic depression as well as major depressive disorder itself. I have to wonder if these aren’t all different ways in which the same illness shows up in a human life.

The research seems to be showing that the apparently milder forms of depression are linked with more severe types. This becomes clear if you broaden the time of research study from months to years. Then you have a perspective that is closer to that of the person with depression.

Is It Depression or Is It Just Me?

These chronic forms of depression are the most resistant to treatment and usually have a long-term impact on cognitive functioning, self-esteem and the ability to feel or get pleasure from life.

According to a summary from the Harvard Medical School: “…[C]hronic depression causes more functional impairment, increases risk of suicide, and is more likely to occur in conjunction with other psychiatric disorders [than episodic depression].”
Most people with chronic depression never seek treatment and probably go through life believing that the illness is just the way they are.

My underlying reason for looking into diagnostic labels and criteria is mostly my concern about what people with depression think of themselves. If you’ve lived with depression for a long time, it’s hard to shake the idea that there is “really” something wrong with you or that you’re faking it because you can’t handle life or one of the other stereotypes that plague us.

These stereotypes, I think, are just as deeply rooted in depressed people as they are in those who don’t want to understand mental illness.

We’re the ones most at risk of confusing the symptoms of negative thinking about ourselves with the reality of our human potential. Because of that concern, I think it’s better to stop imagining that depression comes in mild versions that can be treated like a chronic cough.

If something plagues you for months and years, it’s serious and severe and needs to be at the top of your list of life problems to work on.

(This post is reprinted from the newsletter archive.)