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Q. What initiates the alteration in brain chemistry?
It can be either a psychological or a physical event. On the physical
side, a hormonal change may provide the initial trigger: some women
dip into depression briefly each month during their premenstrual
phase; some find that the hormone balance created by oral
contraceptives disposes them to depression; pregnancy, the end of
pregnancy, and menopause have also been cited. Men's hormone levels
fluctuate as deeply but less obviously.
It is well known that certain chronic illnesses have depression as a
frequent consequence: some forms of heart disease, for example, and
Parkinsonism. This seems to be the result of a chemical effect rather
than a purely psychological one, since other, equally traumatic and
serious illnesses don't show the same high risk of depression.
Q. Is a tendency to depression inherited?
It seems there are some people whose brain chemistry is predisposed
to the depressive response, and others who are at much lower risk of
depression even if exposed to the same physical or psychological
triggers. The genetic relations of manic-depressives are at a higher
risk for unipolar depression than the population at large or their
adopted/by marriage relations. There seems to be a link between high
creativity and the gene for manic-depression: artists and writers
often are not manic-depressive themselves, but have a family member
who is. Studies of families in which members of each generation
develop manic-depressive illness found that those with the illness
have a somewhat different genetic make-up than those who do not get
ill. However, the reverse is not true: not everybody with the genetic
make-up that causes vulnerability to manic-depressive illness has the
disorder. Apparently additional factors, possibly a stressful
environment, are involved in its onset.
Major depression also seems to occur, generation after generation, in
some families. However, depression can occur in people with no family
history of any form of mental illness. And I would be reluctant to
suggest that there is any human who is entirely immune to depression
under all possible conditions.
Psychological triggers: many, if not most, people with depression can
point to some incident or condition which they believe is responsible
for their unhappiness. Of course, people with severe depression are
prone to astonishingly virulent and inappropriate guilt and
self-hatred.
The (genuine) life events that most often appear in connection with
depression are various, but there is one distinguishing feature that
appears in many cases, over and over: loss of self-determination, of
empowerment, of self-confidence. More profoundly: a loss of self, of
the abilities or activities that a person identifies with herself.
Stereotypically: a man loses the job that had defined him to himself
and others, whether that definition was "executive" or "breadwinner";
a woman who had spent her whole life preparing for and living the
role of wife, supporter, caretaker, is suddenly left alone by divorce
or death. In general, any life change, often caused by events beyond
one's control, which damages the structure that gave life meaning.
The ability of a person to respond to such an event will depend on
many factors, including genetic predisposition, support from friends,
physical health, even the weather. It can also depend on internal
psychological factors which may best be explored in talk therapy: why
is the person's self-esteem so bound up in the position or state that
has been lost? Can she find a new source of self-esteem? Therapy can
be immensely helpful here.
Obviously, not everyone to whom this sort of event happens becomes
depressed, and not every person who becomes depressed has had this
sort of catastrophe befall them. In fact, if a person suffers a loss
and then becomes depressed, it may well be that they weathered the
loss in fine style and then succumbed to a much less obvious trigger,
psychological or physical.
Some depressions may well be caused by a spontaneous aberration in
brain chemistry, with no trigger that we can currently identify, just
as a seizure or migraine may have an obvious trigger or be apparently
spontaneous.
However, once the depressive state has set in, both physical and
psychological problems will be generated in abundance. What faster
way to lose a job or a spouse than to be too depressed to work or to
communicate? What worse psychological state for coping with a blow to
identity can there be than a chemically promoted, pathological
self-hatred? And what can be worse for self-esteem than watching
one's appearance and household disintegrate as one loses the
motivation to shower, straighten up, wash dishes or laundry, or
choose attractive clothes? Health deteriorates as well: some
depressed people can't sleep or eat, others sleep constantly (a real
help on the job!) and eat incessantly, sometimes in order to stay
awake, sometimes because it's the only thing that gives a little
pleasure or comfort. (Carbohydrates induce production of serotonin,
so there may be an element of self-medication here); almost no one
has the impulse to exercise or get fresh air and sunshine. Most if
not all of these effects form feedback loops, increasing in magnitude
and becoming triggers for further depression.
The question, "Is depression mostly physical or psychological," is
rather beside the point. Depression may be triggered by either
physical or psychological events. Most commonly, both seem to be
involved, though it is often difficult to separate the two when one
is talking about psychology and neurochemistry. But however it
begins, depression quickly develops into a set of physical and
psychological problems which feed on each other and grow. This is why
a combination of physical and psychological intervention has been
shown to give the best results for most patients, regardless of any
classifications that doctors may have tried to impose on their
depression and its cause.
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