Understanding Depression: What it is, Symptoms, and Treatment
Depression is one of the most prevalent conditions in the United States, affecting millions of people each year, and is a leading cause of disability globally. In spite of its impact, it is also one of the most commonly misunderstood conditions. Popular representations of depression - like 13 Reasons Why and Silver Linings Playbook - present a one-dimensional view of the condition that is easily digestible to viewers, but often fail to capture what people actually suffering with the condition are feeling. In this post, we discuss depression and therapy for depression openly so that if you or someone you know are struggling and interested in learning more or considering getting treatment for depression, you have a resource.
Depression Is More Than Sadness
Most people think depression is simply an unusually intense form of sadness. On this view, depression differs from ordinary unhappiness only in degree: it is what happens when sadness becomes incredibly severe or lasts long enough. This understanding is intuitive, but it misses the real essence of what distinguishes clinical depression and subclinical depression.
Clinical depression is not just a more powerful version of an emotion that everyone experiences from time to time, but a constellation of traits that can seem to take over one's life more globally. In addition to low-mood, most people with depression express feeling empty affectively, having no interest in things that brought them joy (anhedonia), and an increased difficulty with cognitive tasks (such as remembering things, maintaining attention, normal decision-making, etc.).
Although depression does involve intense sadness, for many people depression makes their lives feel meaningless and empty rather than filled with distressing pain. Recognizing this is essential to truly understanding the condition and people that you know who are suffering. Depression doesn't just make you extremely sad about not getting that job offer or being rejected from your dream school, it strips the world of all significance - it's not that you are upset, its that nothing matters.
The Cycle of Depression
Appreciating that an essential feature of depression is the loss of meaning in the world and a perceived failure for their minds to work as effectively is essential to understanding common features of depression. For instance, most people with depression find themselves withdrawing from friends, but many people with depression don't continue their typical solo-activities either - they stop reading as much, stop exercising, stop playing video games. This doesn't happen to everyone, but when it does, it is typically because they feel that they can't concentrate anymore, or that their "brain isn't working". It feels like they have somehow suddenly become bad at everything.
This leads to something commonly known as the depression cycle: You feel bad so you don't see your friends or do things you like to do, which makes you feel worse, which further prevents you from seeing friends and doing things you like. Just like the anxiety cycle (which we discuss here), the depression cycle works against treatemt by making symptoms feel more justified than they are and separating people from the very things that would make them feel better.
Understanding depression as a more global change in the person's understanding of themselves and the world, rather than as an extremely sad state, helps explain why effective therapy for depression is often about more than just reducing symptoms, and why one need not have a depressive disorder to benefit from depression therapy. Therapy can gradually help people recover their sense of agency, reconnect with relationships, rediscover sources of meaning, and begin experiencing possibilities that depression makes invisible.
Sadness and...
Clinical depression is diagnosed according to a constellation of symptoms that persist over time. These include depressed mood, diminished interest or pleasure in activities, changes in sleep and appetite, fatigue, difficulty concentrating, feelings of worthlessness or excessive guilt, psychomotor changes, and suicidal thoughts.
Notice that only one of these symptoms is sadness. As noted above, the thing most people identify and hate about their depression is the feeling that the significance of life seems to have faded away, that they feel emotionally “flat,” that they no longer care about the things they know they should care about. Here is how the essayist William Styron writes about his depression in his book Darkness Visible.
Only days before I had concluded that I was suffering from a serious depressive illness, and was floundering helplessly in my efforts to deal with it. I wasn’t cheered by the festive occasion that had brought me to France. Of the many dreadful manifestations of the disease, both physical and psychological, a sense of self-hatred – or to put it less categorically, a failure of self-esteem – is one of the most universally experienced symptoms, and I had suffered more and more from a general feeling of worthlessness as the malady had progressed. My dank joylessness was therefore all the more ironic because I had flown on a rushed four-day trip to Paris in order to accept an award which should have sparklingly restored my ego. (p. 5)
Styron gestures to something most clinically depressed people feel: the emptiness of life. his was not so much that a feeling of sadness, but, of "dank joylessness".
This distinction is important because, although some people feel the cloud of depression land on them all at once, some people instead notice (or, fail to notice) subtle changes in their behavior that evince early stages of depression.
This is particularly true for teens and college students. Parents often look for signs that their child is doing ok but miss signs of depression because they are looking for the kind of despair they associate with the condition. It can be hard to tell, but if your kid seems more lethargic and irritable, their social life starts to recede and they start to cancel more plans, if their life becomes an increasing slog through schoolwork, then they might be feeling more than just stress.
Is Depression Simply a Chemical Imbalance?
For many years, depression was commonly explained as the result of a "chemical imbalance" in the brain. The idea became influential because it offered a simple, biologically grounded explanation for a complex condition and reduced the stigma of the condition by claiming that depression isa biological condition that could not be helped, except by medicine.
However, studies have failed to find any support for the chemical imbalance hypothesis. Although antidepressants are sometimes an effective element in treatment for depression, study after study shows that medication plus psychotherapy is more effective – not only for depression but for panic disorders and obsessive compulsive disorder (OCD) as well.
The reason is that the feelings of sadness and meaninglessness can arise through other means. Our brains are evolved not just as brute machines with “happy/sad” chemical components, but with sophisticated mechanisms that allow us to ascribe meaning to things. The technical term for this is “intentionality” (not to be confused with the non-technical term "intention" meaning to plan or be thoughtful and deliberate). Consider, for example, that when you see certain things, you see them as something – the chair at home is your chair, the ring on your finger is your wedding ring, the pile of bricks with a window and door is a home, maybe the home you were born in, and so on. But when a cat (or a dog, or a kangaroo, or an alien) sees a ring, for instance, it doesn’t see it as a ring, but as something else entirely.
The point is not about the relativity of knowledge, but that the fact that things have meaning is a product of evolved functions and as with all evolved functions, these can break down. When that meaning system becomes dysfunctional – perhaps because of early attachment experiences, maladaptive cognitive habits, work-related stress, negative social relationships, traumatic experiences, or something else entirely – people become depressed. Psychotherapy helps to understand where the breakage occurred and how to repair it.
What Goes Into a Diagnosis of Depression?
At first glance, the answer appears obvious: depression is a psychiatric disorder characterized by low mood and related symptoms. Yet this definition immediately raises difficult questions. Where does ordinary sadness end and clinical depression begin? Is depression a single condition or many different ones grouped under a single label? Is it biological – a result of chemical imbalances – or psychological – “all in the mind” – or a normal human response that has become overwhelming?
The Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR), published by the American Psychiatric Association, defines Major Depressive Disorder (MDD) as the presence of five or more symptoms during the same two-week period, with at least one of the symptoms must be either depressed mood or markedly diminished interest or pleasure
The DSM-5-TR lists the following symptoms:
Depressed mood most of the day, nearly every day
Markedly diminished interest or pleasure in most activities
Significant weight loss or gain, or changes in appetite
Insomnia or hypersomnia
Psychomotor agitation or retardation observable by others
Fatigue or loss of energy
Feelings of worthlessness or excessive or inappropriate guilt
Diminished ability to think, concentrate, or make decisions
Recurrent thoughts of death, suicidal ideation, or suicide attempts
Although the DSM provides a valuable common language for diagnosis, many clinicians view it as the beginning rather than the end of assessment. Two people may meet criteria for Major Depressive Disorder while differing dramatically in the causes, course, lived experience, and psychological processes underlying their depression—differences that often become central during psychotherapy.
How Depression Manifests Across Different Populations
Famously, from the above symptoms, there are over 200 ways to meet criteria for depression. That is because, as with many disorders, there is an extraordinary heterogeneity – both etiologically as well as phenotypically – for clinical depression. That means that depression can not only be caused by a variety of factors, but that it can manifest in remarkably different ways, often depending on an a person’s developmental age, personality, life circumstances, and social roles. For some, it is characterized by profound and unrelenting emotional pain, whereas for others it is noticeable due to the unsettling absence of emotion altogether; some experience depression as overwhelming hopelessness, while others continue functioning at a high level despite feeling increasingly disconnected from themselves and the people around them. It may present primarily through sadness or hopelessness, but just as often through diminished motivation, anxious sadness, cognitive difficulties, physical exhaustion, irritability, or withdrawal from meaningful activities.
Understanding these different presentations is essential. Effective treatment depends not only on recognizing that someone is depressed, but also on understanding how depression is shaping one’s emotional life, relationships, work, and sense of self.
Parents
People parent differently, but parenting is universally hard. Among parents, depression often presents less as persistent sadness than as chronic exhaustion, disengagement, and feelings of inadequacy. Often one or both parents reports feeling like they are not "enough" - that they are putting everything they can into work, the relationship, their kid, and that there's nothing left over for them. This can lead to resentment and avoidable fights.
Postpartum Depression
Depression in new mothers is sometimes dismissively referred to as “the baby blues”, but postpartum depression can be an intense and isolating experience. Although this often occurs just after the child is born (hence, postpartum), some feel that depression emerge during pregnancy as well. In either case, in addition to a persistent sadness and numbness, mothers typically experience feeling guilty and inadequate as well. In some cases, this involves changes in sleep and appetite, difficulty bonding with the newborn, and even intrusive thoughts that are deeply distressing. More new mothers feel this than is generally appreciated and so many struggle in silence, fearing they will be judged. Postpartum depression is highly treatable and effective psychotherapy can help mothers recover their emotional well-being while strengthening the developing relationship between parent and child.
Professionals
In professionals, depression can frequently hide behind the productivity and outward competence that got the person to that position in the first place. When someone works hard and succeeds, when they genuinely love their work or when it is associated with the source of their value, it is natural to lean into work in order to lean away from feelings of numbness or emptiness. However, when the work itself starts to feel meaningless, or when one’s relationships start to suffer, it is often easier to interpret these problems as burnout or laziness, instead of depression.
Adolescents
At Lexington Park Psychotherapy, we have seen an increasing amount of depression in teens an adolescents – both in high school and in college. Unlike older adults, depression in teenagers and younger adults often expresses itself through irritability, anger, and social withdrawal. Because adolescence is itself a period of emotional and developmental change, depressive symptoms are sometimes mistakenly dismissed as typical teenage behavior.
Relationships
Depression in relationships is not the same thing as depression from relationships. Nevertheless, the emotional withdrawal, reduced sexual desire, and lack of interest in shared activities can sometimes feel like it is a relationship problem. As with anxiety, of the most common ways that people recognize that they are depressed is because their partner has noticed something and encouraged them to go to therapy.
Subclinical Depression
Many people wait far too long before they seek help. Rather than finding a therapist before their feelings worse, they hope it will get better on its own. Psychotherapy is effective for many conditions – including grief, anxiety about trying to conceive (TTC) and pregnancy, relationship struggles, and even just being a teenager – that are not disorders, and are particularly helpful for preventing bad feelings from escalating. Therapy offers a space to speak with a professional who can help you to understand the source(s) of your feelings and address painful patterns of thinking and behavior.
People often get stuck in repetitive patterns – of dating the same kind of person, getting into the same kind of argument, working the same kind of job, and living the same kind of life – that make them deeply unhappy. Therapy can provide some clarity to what it is you truly value and want out of life and help you recalibrate.
Depression Therapy in NYC with Lexington Park Psychotherapy
If depression is affecting your work, relationships, or quality of life, you don't have to manage it alone. Depression therapy in NYC offers evidence-based approaches that address not just your symptoms, but the underlying patterns that sustain depression. At Lexington Park Psychotherapy, our therapists provide individualized treatment to help you develop lasting skills, restore emotional balance, and regain confidence and clarity. If you’re ready to get started, or even if you just need to figure out what comes next, schedule a free consultation with one of our experienced therapists.
