Facts About Depression – B. Types of Depression

Depression is really just feeling sad isn’t it? Well, yes . . .  and no. As my last post on the symptoms of depression explained, to be diagnosed with clinical depression (depression that is diagnosed by a doctor as opposed to ‘feeling depressed’) must have at its core, the combined symptoms of 1) feeling sad and/or 2) losing the ability to enjoy whatever was pleasurable in the past.  So yes depression has ‘feeling sad’ as a major factor, but no it isn’t JUST feeling sad. It’s much deeper than that.  As we saw in the last post, there are many symptoms of depression. There are also quite a few different types of depression. Different types sometimes produce different symptoms. Knowing what type of depression a person has is important as their treatment will vary depending on what kind it is.

Now, I’ve found that sometimes when talking about depression in detail, there are Christians who say (or think) that its focusing on the negative and that by learning more about it we are actually giving Satan power, or lessoning our faith. But this is another of those areas where if it was a physical ailment – say diabetes, asthma etc., there would be no problem with someone examining the facts about the illness in order to understand it and to better help themselves or their loved one.  There are at least two scriptures that talk about God’s people perishing for lack of knowledge - Isaiah 5:13, Hosea 4:6. So if God doesn’t have a problem with His people increasing their knowledge base, why do we?

However as there is a lot of information 'out there' on depression, and some of it seeming conflicting, I have spent much time researching from reliable sources and compiled the following in an easy-to-read/layman's style resource that you can use as a basis for understanding your, or a loved one's depressive illness.

The most common kind of clinical depression is  often just called ‘major depression’. But the symptoms can vary hugely depending on whether a person has it in a mild, moderate or severe form. As we will see when we look at treatment in an upcoming post, they are treated quite differently. For example, a person with mild depression may improve with only basic help (lifestyle & cognitive changes, etc.), while in someone with severe depression those treatments will have little or no effect. 

Below is a list of the different types of clinical depression and some basic information on each:

Major depressive disorder is also called major depression, unipolar depression, recurrent depressive disorder and sometimes just clinical depression. It may involve a single episode, may be recurrent or chronic. You can have mild, moderate or severe major depression depending upon the number, type and severity of the symptoms. Someone may experience a mild, moderate or severe depression only once in their life, or they may have several episodes. Sometimes especially if it is not dealt with promptly and correctly, a person may progress through from mild to severe over one or many episodes. The more times a person has an episode of depression, the harder it becomes to treat successfully (more on this in the post on treatment, coming up), which is why its important to get help early on.

o    Mild major depressive disorder. The symptoms impact on daily life but the person is still able to function. They may experience less motivation and may find it harder to keep up with normal life activities. There is usually a reduced loss of interest in things they used to enjoy. Often these symptoms are only noticed by those close to the person. Treatment usually consists of lifestyle changes and some form of psychotherapy/counseling, with medication added if necessary.

o    Moderate major depressive disorder. The loss of interest in normally enjoyed activities is noticeably worse. The depression interferes to a greater degree with social lives, work activities and relationships. Simple things seem difficult. Self-confidence and self-esteem take a dive. A person will often withdraw from social activities and their loved ones as they struggle to deal with their inner distress. Thoughts of death may be vague or may start to take a stronger hold. As well as lifestyle changes and psychotherapy, treatment will almost always involve some medication, and it may take several attempts to find the right one.

o    Severe major depressive disorder. It becomes impossible to continue as normal with work activities. Most social activities cease. Friends and family will be able to tell something is very wrong. Feelings of hopelessness and despair become overwhelming, as do guilt and lack of self esteem. Thoughts of wanting to die become very real and suicide is a very real danger. Although not common, severe depression may also involve:

•  psychotic features (may also be called psychotic depression) where the person may have hallucinations (seeing and hearing things that do not exist) or delusions (false beliefs) and there are often more severe psychomotor disturbances. The hallucinations or delusions are negative in nature and often involve a sense of ‘nothingness’.
•  catatonic features such as extreme disturbances or slowness in movements and speech.
•  melancholic features (see below)

Treatment may involve more than one medication. Electroconvulsive
therapy may be used. Lifestyle changes are not usually possible as the
person has sunk so low that they are not able to make the changes
necessary. Psychotherapy is often not helpful until the person starts their 
recovery as their cognition is so affected by the severity of the depression
that they are unable to be actively involved in any form of talk therapy.
Medication is usually the only way to begin to move forward for most
severe depressions. When the symptoms have improved the person can
then begin to implement lifestyle changes and psychotherapy.

Dysthymia. This was described in the past as depressive personality disorder and is sometimes called chronic depression (although the term 'chronic depression' can also be applied to moderate and severe depression). It is a chronic, long lasting, mild form of depression where a low mood is experienced for most of the time with the overall disturbance less severe than with major depression. Dysthymia has less symptoms than major depression, and they are usually less intense. But they must be present for 2 years or more for it to be diagnosed as dysthymia. The person may have some good days at times, but the negative symptoms always come back. It can begin in childhood or early adulthood and often people do not even realize they are ill as it is the only way they have known and so may think it is just part of their character. Dysthymia often requires a longer treatment time than major depression and involves both medications and some form of psychotherapy. Medication alone is not enough as the person usually has ingrained thoughts and behavior patterns developed through years of depression. At least three quarters of people with dysthymia also have a chronic physical illness or other psychiatric disorder (i.e. anxiety disorder, alcoholism). People with dysthymia have a higher than average chance of developing major depression. Like major depression, it has a genetic component.

Atypical. This has many of the symptoms of major depression with over-eating, over-sleeping and fatigue being more pronounced. It may overwhelm a person so much that it causes a greater functional impairment in some areas than other forms of depression, sometimes to a point of emotional paralysis which sees them spending all their time in bed.  They may be more sensitive to rejection and may experience a feeling of being ‘weighed down’. The main difference with atypical depression is that the person’s mood responds to outside events. Often beginning in the teenage years, and more common in females, atypical depression is often present with other mental illnesses (i.e. avoidant personality disorder, social phobias). It is important to have this diagnosed by a professional, as people with atypical depression respond better to certain treatments than others.

Bipolar depression  This is the name given to the depression experienced by people who have bipolar disorder (previously called manic-depression, also referred to as bipolar affective disorder). The depression experienced as part of bipolar is generally of a melancholic (see below) or/and psychotic nature and can be very severe. The main features are a severely depressed mood and psychomotor disturbances (i.e. movements are slowed or agitated, hard to concentrate, physically hard to do every day things). It primarily responds best to drugs although counseling or psychotherapy will be helpful also. It is important to have a specific diagnosis of either unipolar (depression only, with no manic symptoms) or bipolar depression, because the management can be quite different. For example, some antidepressants given to someone with bipolar may cause a fast escalation to a manic state. Bipolar does have a strong genetic component and is often triggered by a stressful event. There are two main types of bipolar - bipolar I and bipolar II and a third less common form, cyclothymia.

o    Bipolar I This is the most common and is where the sufferer experiences episodes of mania (abnormally elevated energy levels, mood and cognition) and of depression.  They are usually separated by periods of ‘normal’ mood and behavior, although in some cases the mania and depression may alternate rapidly (rapid cycling) and may even merge, which is know as a ‘mixed state’.  In some cases the manic episodes may include symptoms such as delusions or hallucinations and the person’s self perception may be so deluded that they may act unsafely.

o    Bipolar II The sufferer experiences frequent or chronic severe depression with either very mild mania or short lasting mania called hypomania. This may be seen as irritability, racing thoughts, anxiety and/or sleeplessness and does not usually include euphoria. Because mania is often perceived only as an extreme elation in mood, an episode of hypomania may not even be recognized. It may just seem as though the person is having a ‘good day’. Rapid cycling, where someone experiences manic or depressive episodes more than 4 times in a 12 month period, is more common than with bipolar I. Bipolar II sufferers are at a higher risk of suicide than bipolar 1.

o    Cyclothymia This is a milder form of bipolar, where a person experiences some mood swings but remains connected to reality. It may develop over the course of a person’s lifetime to become bipolar disorder or recurrent depressive disorder.

Double depression This when a person with dysthymia (mild depression lasting more than 2 years) experiences an episode of major depression. Medications are almost always needed as the goal is to get the person not only to feel better than they did before the major depressive episode but also before they had the dysthymia. Psychotherapy is also essential in treating double depression. One distinguishing symptom of double depression seems to be hopelessness. People have a very bleak outlook on their life and have given up on hoping it could ever improve.

Perinatal. Also called postnatal/postpartum if after the birth of a baby, or antenatal if during the pregnancy. This affects almost 16% of women giving birth in Australia. It’s not the same as the ‘baby blues’ which is often experienced a few days after a birth. Postnatal depression occurs in the months following birth and can become quite severe. A woman is 7 times more vulnerable to depression after childbirth than at any other time in her life. Unfortunately a woman who has had postnatal depression has an increased risk of it recurring with subsequent pregnancies and of developing bi-polar disorder.

SAD – seasonal affective disorder This refers to episodes of depression that occur every year usually during autumn and winter. It often begins in the teenage years or early adulthood and is found more in women than men. Exercise and increased outdoor activity may improve symptoms.

Depressive Disorder Not Otherwise Specified is a term used to describe a mood disorder that does not fully meet the criteria for any of the other categories. It covers

o    premenstrual dysphoric disorder - having depressive symptoms for a period of at least 1 year, in the 2 week period surrounding menstruation that are severe enough to interfere with everyday life activities.

o    minor depressive disorder - episodes of longer than 2 weeks' duration with more than 2 of the symptoms of major depressive disorder

o    recurrent brief depressive disorder - episodes of between 2 days to 2 weeks of symptoms of major depressive disorder, not related to menstruation, but present at least once a month for a year

o    schizophrenia related depression

o    when a there is a definite depressive disorder, but it is unclear if it is related to a medical condition or the effects of drugs or medication

Grief. I have included this here as a ‘type’ of depression as depression  is considered ‘normal’ for those who grieve a loss - be it the death of a loved one or the loss of a job - to go through a phase of depression. This is not classified as clinical or major depression and should dissipate with time. For some people though, it may well become more serious and if not resolved may be the beginning of a depressive episode.

There is a difference between grief and depression, although both contain similar elements. With depression  the predominant mood is sadness mingled with hopelessness and despair. The severely depressed person often feels that this will go on forever and that their future is bleak. Their thoughts are usually very self focused, in a self-negating way with self-loathing and very low self-esteem and they will withdraw from their loved ones. The sadness is constant and does not change. Usually a depressed person cannot be consoled or ‘cheered up’. Nothing can penetrate the despair, and suicide may be thought about and seen as the only option to end their emotional pain.

In contrast a person going through a sense of depression as part of their grieving will find that their feelings of sadness often coming in ‘waves’ in response to a reminder of the deceased and will be intermittent, mixed with positive thoughts and memories. They are more likely to see that one day their life will get back to ‘normal’ and are able to respond and be encouraged and uplifted by the love shown to them from others others. Their self esteem and emotional connection to loved ones are usually intact. Although sometimes a grieving person may fantasize about joining their departed loved one, they do not seriously contemplate suicide.

When a person is recovering from major depression they may go through a time of mixed symptoms of depression - having some good days and some bad, which may look similar to the 'grieving depression'.

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There are also some other commonly used terms which you may come across:

Melancholic and non-melancholic depression  Melancholic (sometimes called endogenous or biological depression) describes a type of moderate to severe major depression with a strong biological and genetic component. It's symptoms involve psychomotor disturbances, becoming physically slowed down, slowed thinking, sleep and appetite disturbances and/or feeling agitated. It only affects 1- 2 % of the population, affecting men and women equally. It very rarely goes away on its own and responds best to medication and only minimally to counseling or psychotherapy. Mood and low energy are often worse in the morning with improvement at night. Non-melancholic (sometimes called reactive depression) means that the depression is not primarily biological, but has to do with how a person copes with stressful events and/or their personality style. It is the most common type of depression. The symptoms are typified by worry and anxiety. People with this type can sometimes be cheered up to some degree. It has a high rate of spontaneous remission and responds well to a combination of treatments (i.e., counseling, psychotherapy, medications) and affects more women than men.

Smiling depression (also called concealed or hidden depression) is a term used when a person is depressed but hides it from others. They appear to be active and social when with others, but inside are suffering the sadness or numbness of depression. They are able to function to a certain level on the surface but are suffering inside.

Anxiety is not the same as depression but is often associated with it. While they do have a lot in common they are separate conditions and may require different treatments. Both can contribute to the development of each other, sometimes with an overlap of symptoms. The key features to anxiety are worry, fear and panic usually about things that may happen in the future, while depression has sadness, hopelessness and despair as it’s main factors and is more focused on negatives about the person while seeing the future as hopeless. Depression exacerbated by anxiety has a much higher suicide rate than depression alone. 

So you can see that depression is not simple . . . there are many different types as well as many different symptoms of depression. There are also varying causes of depression, with factors which affect the risk of, and resilience to, developing depression. If you can pinpoint the cause or risk factors at play in your or your loved one’s depression, its more likely you will be able to work on getting the appropriate treatment. We’ll look at the causes of depression in my next post.