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.
Full Recovery
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.
Residual Symptoms
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.
Long-Term Changes
The changes depression brings with it can reach into many dimensions of your life: biological, psychological and social.
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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.
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Psychological:
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.
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Biological:
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?
Image by Cane Rosso at Flickr
Depression is good at multi-tasking. It is right there, almost a step ahead of you, in every dimension of life. Not only in the expression on your face (unless you can hide it), but in the slowness of movement, in the constant effort to pull yourself into the present (hence fatigue), in the awareness of what must be done at work and at home in order to keep your job and your house. And always is the background a nagging sense of displacement, disengagement, dishonor.
I experienced this daily for at least 3 decades. Chronic depression. It became a way of life. I can’t say I made the best of it or that I was even always aware of it, because your mind can’t withstand torture every waking moment. I knew I was in a battle for my life. I really only realized the full extent of its effect on me when I started “waking up” to color in my surroundings, heard the sound of my own laughter again, and could fully engage in conversations at least mentally. Most of that time I dated, got married, held down jobs, went to holiday family gatherings, took care of sick parents, ate and drank and did the laundry.
But when I started “waking up” I also realized how much depression had changed me. I didn’t know how to make friends anymore. I was afraid of making a friend because of that cautiousness mentioned in this blog post — I might make a friend then become so depressed I would have to abandon them. Also I tried to start doing the things I used to enjoy, only to begin…and sit there in a daze. Something like I imagine recovering from severe head trauma might be in a very, very limited way. Like I had to re-learn how to do everything knowing it would never be as easy again. It was overwhelming to realize how much I had missed and could NOT recover, and then have to be content to just be alive.
This has given me incredible closure knowing that those in the “others” category, myself included, virtually have very little hope. It sounds sarcastic but it’s relieving to know I can stop trying and accept my future and the way I will live and suffer for the rest of my life.
I have a question. I watched the movie “This is where I leave you” and one of the characters has depression and and she said because of her depression medication she has no filters. Is this true? Can you let me know what the word that describes this? She used it in the movie but I forget what it was.
Thank you.
Terry
My medication completely took my filter off. I say all kinds of things and I’m not afraid to say certain things to people like I used to be. I like it.
49 years old, depression since my late 20’s Antisocial introvert adrenaline junky. Just diagnosed with PTSD 10 years after getting out of the military. No sense of purpose and almost nothing makes me happy any longer. Add to it an unwanted divorce and never ending child custody battles. I’m ready to run away and live in a cave far from “civilization”
I had a really difficult time in my last couple years of high school especially my senior year. I would cry almost everyday at school and when I got home. I never told anyone what I was going to through until one day, at school it just got too much. I don’t think my parents even knew but that day I told them I was diagnosed with clinical depression. I still didn’t really know what is was then none of us did. I went to therapy but only for a few months because I was graduating and was feeling a better. Then I went to college away from my family and friends. The first semester was good I had made lots of new friends was having fun and studying hard but struggling (always had a hard time in school), but then the depression started to come back. Then some things happened that kind of knocked me down further. And then my grades started to fall. I didn’t really know what was happening at the time. At first I didn’t tell my parents I didn’t want to worry them and though I could just get through it. Of course if didn’t work and went to the school psychiatrist and was prescribed medication. I didn’t see any many friends anymore, and the friends I did see we would stay up all night and smoke and drugs. Then overtime as things got worse I wanted to spend more and more time alone. But then also the loneliness was too lonely. I started smoking more as a way to cope, but also because it’s all my friends did. I guess I was spending to much time alone the I developed social anxiety. I guess I was a bit quiet before but I’ve always had lots of friends and never social anxiety. After a year I was having a really hard time, I guess I hit rock bottom. One day I decided I wasn’t smoking anymore and I didn’t. But after that I was still in pain. I tried to take my final exams but couldn’t and decided that it was best to go home and continue therapy. Now I’ve been at home since Jan, and looking back I have changed a lot for the better. But I do look back a lot at the person who I used to be, the person who liked going to parties and meeting new people. Who would smile more and laugh more. Who loved to socialize and be with friends. I’m always wanting to be that person again. People say that if I was doing it before I’ll be able to do it again. I some what believe, that but I can also feel that I have changed after experiencing that episode. But I don’t know what exactly has changed, it’s kind of like the light inside me is a little dimmer, and I don’t think it will be as bright as it was before. I think part of that is also because I haven’t forgiven myself for the past, and accepted it. Whenever memories from that year come back I get a tightness in my chest, and I can kind of feel the anxiety and sadness that was there. And I just want it to be erased. But maybe it’s not about forgetting what happened, its about accepting that it happened. I guess now I don’t really know what to do. I feel like I’m either thinking about the past or the future and not being in the now. I guess I don’t really know what to do now, I’ve just enrolled in a online design course. But then I feel like I’m not really living life. I feel like I spend to much time at home or with family. But then I know that it will happen eventually and naturally. I just feel like I’m not really living. Excluding the traveling, I feel like since I’ve been home I haven’t really done anything. People say that this is a time for me to grow and learn about myself, I haven’t really done much since January. But then at the same time I don’t know what to do.
Thank you for sharing this. I relate to a lot of what you said… especially about feeling like the light inside you is dimmer. I was a social butterfly before depression hit and even though I’m not experiencing severe depression like a few months ago, all I want to do is stay home and hide from the world.
I 100% relate to this. 200% in fact. I really think you’re onto something when you say “self-forgiveness”, or just forgiveness all around. I’m fixing to go to therapy with that subject matter as the leading issue I think. Took some time to come to that realization, but awareness takes time! As for the reflection on your former self and all the laughing and such, I think you might just have to get accustomed to living a more sober life. One where you aren’t using drugs (even booze is a drug) to cover up any insecurities or make you more outgoing. This is totally ok! In fact, by doing so you will slowly gain more self-understanding, self-acceptance, learn to be happy without it, find new friendships that serve you the same, and even grow spiritually as you would be more connected to God. That light may feel dimmer but it is THERE. What we must realize is that often times, when our light begins to flame out, it is the light of others that can rejuvenate ours…just like from one match to another. That is the impact our lives have on other peoples’, but we must be willing to be brave and stick our necks out there. Have patience with yourself, keep the faith, keep doing the work, find supportive people you can talk to (a GOOD FITTING therapist helps!), slip in some prayer and scripture, and EXPECT a breakthrough!! Sometimes our expectations can be so hard wired based on our past that we fail to see what a new, emboldened life can even look like (and most like would be). If traveling really sets you free, take the chance and get your eyes feasting on new environments. That can also help break you out of a one track mindset. You got this, Alix! I promise.
I want to share my story I have been blessed with very good parents always I have being treated like a princess all the time the thing is that I never felt confident and firm and beautiful never truely I m beautiful but this is my weak.point when anyone looks at me or speaks to me I don’t feel to look back or speak to any one when I was a child I have developed myself as a loner I have been always being alone when someone looks at me I feel hatred I feel like I would.kill them I can’t do things I needed to do I always dreamt of being someone big great but being a loner neither I would allow myself to mix WID people nor did I want to talk or ask help from anyone I used to always keep my eye outside from my home but I would never try to mix up … When I tried to mix up with my age group people I never felt happy coz every 1 was too much over actors and they had been I’ll treated by their I wold never mix up with my age group or people with people elder then me coz I won’t tolerate them any one not even kids I used to feel guilty always and even though I wanted to achieve the best I could I would never come out from home I have developed a huge shyness I can’t even express u I would never talk to any boy or Learn anything coz of my shyness and would always be with my parents always they thought she likes to be with them so they too enjoyed but I would treat them as friends whatever bthey would say me I would never follow coz I always felt that they are talking friend ly not serious my 10 score was 78 .%and in 12 I scored 60 % and then following the so called trend I opted for engineering there also I would seerch a friend I was not studying not even I took my studies serious ly I didn’t engineering 3 yrs the people there were so advanced and so forward these also I would not be able to fix my self then avoiding all and everyone I would spent my whole life sitting at home nearlynow I don’t know anything about the life where is what and Al the way I travel Lee alone due to this I had being got growth of unwanted hairs on my face belly so even more I m feeling so shy I always try to focus on what to do but m unsussesful in deciding what I really like to do I haven’t developed my speech and my mind so I talk very less or almost I used to not talk the whole day. I used to take things directly on my heart I would laugh at anyone and would go with anyone w/o anyone s consent would just run rylun run now I need my final yr I m always trying to save my life nad myself from people around I hate to talk to anyone but I always feel to make a friend a true friend who understands.me love me take care and giude me I will achieve great things but I really don’t know I don’t know how to make myself more active and fight doe my self I was topper
I completely understand how you feel. For years I didn’t understand why I desperately wanted friends but at the same time I found it difficult to be around people. I find it hard to make friends and keep them. I also find it hard to be around people for too long as I am then desperate for my own space. I have come to accept that I am an introvert and that’s what introverts are like. I have met people like me in the past few months and it helps to know I am not the only one. Someone once said to me that I needed to learn to love myself. I went away feeling quite annoyed but they were right. I do love myself now and have accepted myself for who I am. I think that is an important step in being able to make friends. If you can love yourself then you can learn to love others. I am discovering the more social situations you put yourself in the better you get at being around people and finding things to say. Be kind to yourself and allow yourself the luxury of making mistakes socially. You can only learn from it and do better next time. My friend said to me when she first met me that she was socially awkward and that really helped both of us. It helped us both with our conversation and understanding each other. There are more people out there with the same problem then you may know. Sometimes you can feel alone and feel like no one else understands you but you really are not alone. You just need to find that one person who understands how you feel. As a Christian I have often told Jesus and my Heavenly Father how I feel and he has always been there to help me, guide me, comfort and support me. I have heard his voice in my deepest darkest moments. He has always been there, my truest and my most amazing best friend. If you are ever in need of a friend who will never let you down, then ask Jesus to be your friend.