On Depression

Written when I was a senior at Stanford.

At the start of the quarter, I promised many of my friends that I would make a blog post during winter break compiling all my notes together from PSYCH 234: Understanding Depression.

Looking back at my notes, I realize that there’s about ten pages worth of material I could include here in the blog, so I decided to instead include what I think are the most interesting and surprising insights I have gleaned from the class. For those wanting more, I have attached the link to the full document of my notes at the end of this post, but read it at your own risk! It’s a tad messy and hard to follow.

A brief note about PSYCH 234 before I begin: the class was divided thematically, each week, into two sections. The first section usually discussed readings that were assigned over the weekend, and the second section was more lecture style, where Professor Gotlib supplemented our current information with further knowledge. Most of these notes will be from this second section, but if I mention any readings or documents, I will be sure to add a link to them, for your reference.

Lastly, I would like to add one important caveat. Having taken this class on depression, I, by no means, am going to pretend to be an expert on the subject. Please feel free to shoot me an email at amritav@stanford.edu if anything in this post is offensive or just simply wrong. I promise to correct it to the best of my abilities.

With that all out of the way, here we go!

I think I’ll start off with one of the first questions we asked in class.

The word “depressed” is thrown around an awful lot. What does it mean to actually be depressed?

According to the DSM (Diagnostic and Statistical Manual of Mental Disorders), for one to be clinically diagnosed with depression, he or she must have 5 or more of the following symptoms consistently for 2 weeks, including at least 1 of the first 2 symptoms. These first two symptoms (bolded below) are often referred to as cardinal symptoms.

• depressed or irritable mood
• diminished interest, loss of pleasure
• weight change
• sleep difficulties
• psychomotor agitation or retardation
• fatigue
• feelings of worthlessness or guilt
• concentration difficulties
• recurrent thoughts of death, suicidal ideation

Women are about twice as likely to be diagnosed with depression than men. Why is this?

Here’s one reason: because women in general tend to openly express sadness and grief more than men do, it is often easier for women to receive a diagnosis. In fact, it could be the case that there are just as many men who are depressed as women, but they don’t receive a diagnosis due to the specific DSM criteria shown above. Because of this, there have been many researchers pushing to change the criteria which would address gender specificity when diagnosing a disorder like depression.

Here’s another more interesting reason: women, scientifically, have a larger “circle of care” than men. What this means is that women tend to care about a much wider range of people than men do. This begets unfortunate or negative scenarios to occur; essentially, by caring about more people, you have more chances to get hurt or feel upset. And these potential tragic or traumatic events can prompt depressive episodes. Check out this paper by Kessler and McLeod on the relationship between sex and psychological distress to read more about this.

What role does a general practitioner play in a patient who has depression?

Want to know something crazy? 95% of medication for depression is prescribed by the general practitioner (GP). Only 5% is prescribed by an actual therapist or psychiatrist.

Think about your last visit to the doctor for a physical or regular checkup. Chances are your GP spends no more than 7 minutes with you before moving on to their next patient. Yet, these are the doctors who are prescribing antidepressants to patients who report feeling depressed or suicidal.

Why is this? If you think about this from the GP’s perspective, it makes some sense. As of now, Prozac, the most common antidepressant, has no real side effects. The cost of a false positive is very minimal. This means that if someone who isn’t actually depressed takes Prozac, nothing really is going to happen. However, if a GP sees a patient who reports feeling depressed, chooses not to prescribe them Prozac, and then the patient commits suicide, he/she is in MAJOR trouble. So GPs tend to overprescribe, in order to cover their own asses.

This is not a dig at GPs. It’s a tough situation to be in. But it does make you think about the fact, that, in general, antidepressants are WAY overprescribed. And psychologists and doctors alike, are hoping a system will be put in place soon to prevent this from happening.

Why hasn’t evolution gotten rid of depression already?

This is an interesting question that can be extended to a lot of different disorders, not just depression. In this paper, Nesse argues that depression can in fact, be an adaptation. He argues that it is an adult human’s way of signaling a need for help. However, there is not enough evidence to say for sure. In fact, Nesse concludes by saying that “even though low moods and sometimes depression may be useful for inhibiting dangerous or wasteful actions, that should not distract attention from the fact that depression is one of humanity’s most serious problems.” So, TLDR, we don’t really know why evolution hasn’t gotten rid of it.

What about suicide?

Kind of going off the last point just made, there is still a lot of psychological questions surrounding why humans commit suicide. It is, evolutionarily, the opposite of what our body is naturally designed to do. Someone asked in class, actually, if other species commit suicide. It was remarked that dolphins in captivity are known to kill themselves, which is shocking since dolphins have some of the most advanced brains in the animal kingdom.

Our professor also noted that mother gorillas who have lost their offspring in some sort of accident would choose to just stop eating and eventually, would die. This begs the question, do these gorilla stop eating with the intent of killing themselves? Or are they just so sad that they have no energy to eat and have no real idea that death is a natural consequence of that?

This is a common question that is also asked about young kids who commit suicide early (at around ages 6 – 8). At this age, are they truly aware of the finality of death?

How does depression play out in marriage?

One of the more prominent characteristics of depression is dependency, or the constant need of interpersonal support. For this reason, many people (women in particular) who are depressed, tend to get married early. In fact, comorbidity (the simultaneous presence of two diseases in one patient, often times anxiety and depression) is a huge risk factor for early marriage. And not only do depressed women marry early, but they tend to marry men who are much older and often times abusive, taking advantage of the fact that their spouse doesn’t have the mental stability or energy to leave the marriage. This is one of the most heartbreaking facts about depression. Those who are depressed tend to isolate themselves from those who are not which only heightens their sense of loneliness and neglect. For this reason, many depressed people tend to marry others who are also depressed or anxious, entering into rather tumultuous marriages. As you can imagine, the divorce rate for depressed couples is exponentially higher than the average divorce rate in the U.S.

Is depression genetic?

This is perhaps the most popular question involving depression. Basically, if my mom is diagnosed with depression, does that mean I am guaranteed to be depressed as well?

Yes and no. You don’t inherit depression. You are not born depressed. What you can inherit is a tendency to experience depression; you inherit vulnerabilities to personality traits or cognitive styles, which themselves increase the risk of developing depression Examples of these could be high neuroticism, low self-esteem, or low sociability. Not to mention, if you are raised by someone who is depressed, especially at a young age, you are constantly at the receiving end of irritable or depressive mood states, which can be a huge contributor to your disposition as you get older.

But no, you cannot inherit depression like you would inherit eye color.

Here are some other random factoids I’ve learned in the class that I wasn’t sure where to put.

• Religious attendance protects against major depression.
• The response to treatment for depressed patients is around 66%.
• In 2017, Harvard University conducted a study which used a user’s Instagram photos as predictive markers of depression. The study had almost a 75% percent accuracy with its predictions. An average therapist predicts a patient’s depressive condition with 40% accuracy.

And of course, here is the link with the rest of my notes.