The Brown and Blues
November 30, 2007
Your history assignment is depressingly long. You’re depressed that the days are so short and the sun is setting so early. And nothing depresses you like the prospect of another chicken patty lunch at Dewick. All in all, you’re feeling pretty down. But even if everything at the moment seems “depressing,” you’re not necessarily “depressed” — at least, not in the clinical sense.
Depression is a broad and multi-faceted subject. Everyone has days when they don’t feel like themselves — it’s only human. The challenge for psychologists, doctors and researchers is to determine when “the blues” have crossed the line and become the psychological disorder known as depression.
Depressive disorders, as the afflictions are formally known, all have several characteristics in common. They are persistent — whereas a “bad mood” may pass within a few hours or days, untreated depression can last for weeks, months or even years. A person suffering from depression, try as he might, is usually unable to “pull himself together” and recover, a frustrating feeling that often exacerbates the condition.
Depression is also usually characterized by an intensity that is sufficient to cause disruptions in a person’s day-to-day life. Apart from these similarities, the various triggers, symptoms, and treatments of depressive disorders are extraordinarily diverse.
When Sadness is Nice
An anonymous Tufts freshman describes how he feels when he is depressed: “I constantly feel doubt and helplessness. I feel like I have more negative thoughts than others. I wouldn’t classify it as sadness. I think sadness would be nice. Sadness seems to imply an ability to reach happiness.”
No number of descriptions, no matter how accurate or eloquent, can truly convey the feeling of depression to a person who is not depressed. Depression elicits such extreme emotions (or in some cases, such extreme lack of emotion) that even people who have experienced depression but recovered sometimes have difficulty remembering or sympathizing with the feelings of their former, depressed selves. By the same token, people with non-depressive psychology often are simply unable to relate to the depth of the sadness a depressed person is experiencing — the saddest sad that such a person can imagine is still nothing compared to the sadness felt during clinical depression.
The impossibility of true empathy for depressed people is one contributing factor to the stigma that surrounds depression in our society.
The Stigma
It’s no accident that 80 percent of depressed people are not currently receiving any treatment, or that 41 percent of depressed women are too embarrassed to seek help, according to a National Mental Health Association (NMHA) survey and the 2003 National Healthcare Quality Report, respectively.
While college students tend to wear their stressful and sleepless lifestyles as a badge of pride, depression is far from glamorous. In fact, by many accounts depressed people are stigmatized and the word “depressed” is used as a pejorative. A number of reasons have been suggested for why this is.
First of all, society in general does many things to perpetuate stereotypes about mental health issues. The images with which depression is often associated — self-injury such as cutting, suicide, psycho killers or disgruntled stalkers — are considered “mental illness” along with depression.
An information packet released by the Mayo Foundation for Medical Education and Research (MFMER) explains that “mental illness remains the butt of jokes in popular culture. Negative portrayals of people with mental illness fuel fear and mistrust and reinforce distorted perceptions, leading to even more stigma…this perception is often inflamed by media accounts of crime…some people also believe that those with mental illness are less competent, unable to work, should be institutionalized or will never get better.”
It is easy to fall into the trap of stigmatizing those with depression. The ideas of cutting and suicide are indeed troubling, and can be extremely uncomfortable for most people to think or talk about. Leading the stressful or challenging life you probably do, it’s difficult to sympathize with depressed people: their lives don’t seem any harder than yours, so why should you pity them? Why do they deserve coddling and special treatment, when you yourself cope with life just fine? In fact, many depressed people hold their depression against themselves.
The same anonymous student describes the worst part of being depressed as “wanting to cry, but not being able to. Knowing that sitting there on your bed wanting to cry is the most pathetic thing. Knowing that complaining about depression is even more pathetic.”
Many people do not realize that people with severe depression or other “mental illnesses” literally cannot do anything to help themselves, just as a person with a fever (a “physical illness”) is incapable of voluntarily bringing his temperature down.
“To some,” continues the MFMER packet, “‘mental’ suggests not a legitimate medical condition but rather something that results from your own doing and your own choices. People may blame you and think your condition is ‘all in your head.’ They may think that mental illness is an indication of weakness or laziness, that you’re a ‘moral failure’ or simply ‘can’t cut it.’” This simply is not the case, since depression is usually triggered by things outside of the victim’s control and governed at least in some part by biology.
Still, according to NMHA, 54 percent of people believe depression is a personal weakness.
The Many Faces of Depression
“Depression has many faces,” says Tufts staff psychologist Julie Jampel. There are several different categories of depression, each marked by certain symptoms having different physiological causes:
First, there is dysthymia, a mild but long-term form of depression which, to meet the clinical definition, must persist for more than two years.
Many people find that their moods are heavily influenced by the time of the year, becoming more prone to depression in the winter. This is attributable to seasonal affective disorder (SAD), which affects more that four million Americans each year, according to the National Institute of Mental Health (NIMH). A less common form of depression is manic depression, or bipolar disorder.
Some believe that there is one more, as-of-yet unnamed category of depression — one mild enough to often go undiagnosed, but still potent enough to be considered pathological. This type of depression might arise as a result of some stressor, such as an upcoming deadline or a relationship gone afoul. These are characterized by a self-critical or low mood or a sense of inadequacy.
What kinds of depression are prevalent at Tufts? Ms. Jampel says that, while there is no archetypical “depressed Tufts student,” depression on campus manifests itself in two equally-common ways. “One of [these] is the sad presentation,” she explains. “What you usually think of when you imagine a person who is depressed. Such a person cries easily, they may have trouble sleeping, trouble eating, trouble taking care of themselves…they may have trouble concentrating, getting their work done, but basically, they’re crying a lot and not functioning well.” This can be triggered by a specific event, like a breakup or a tragedy in the family, or it can simply be caused by an amalgamation of environmental stressors.
“Another way depression looks on a college campus,” Ms. Jampel continues, “is that there are people who are unmotivated and uninterested. So it’s not like they’re sad, it’s not like they’re crying. But, maybe they used to enjoy their studies, and they had things that they do, they liked being with their friends, and they’re not that interested in things anymore. They’re not following through, they’re not making plans, they’re not doing things they usually like — stuff like that is also depression.”
Although the Tufts counseling service does treat people with bipolar disorder, these cases are rare. Statistics for how many Tufts students suffer from the various depressive disorders are not available; however, the school is currently conducting a study called Healthy Minds on Campus, which should yield more detailed information. Nationwide, NIMH reports that in a given year 9.5 percent of the adult American population, or about 20.9 million people, suffer from a depressive illness.
The Chemistry of Depression
How does a person get depressed? Despite a large amount of scientific research in the field, the exact physiological reasons are still unknown. Tufts psychology professor David Harder explains: “It’s not so clear what the brain mechanisms [that cause depression] are. There are certain activation patterns that people have noticed that seem connected with depression, but in other studies they often aren’t replicated…generally, though, there seems to be some deficit or a lower level of activity in the serotonin transmission pathways.”
Serotonin is a neurotransmitter that is known to cause mild excitability and happiness when released in the brain. (In fact, there is speculation that the reason so many people love chocolate is that it contains high levels of serotonin). Many experts believe that a lack of serotonin is at the root of depression. Again, the exact mechanism is unclear. It could be that certain people have less serotonin available in the first place, and are thus more prone to depression. Alternatively, it could be that serotonin is not released as frequently or does not stay in the synapse as long as it should. The human brain contains serotonin receptors all throughout, so the pathways causing depression may not be confined to a specific locality of the brain like many other mental disorders.
Much of the scientific investigation of depression has been directed at discovering what triggers it in the first place. Psychologists have come up with a number of theories. It is not too surprising that tragic or negative events in a person’s life — a tough break-up, the death of someone close, academic difficulty — can trigger depression.
But these triggers don’t account for all of cases of depression. As it turns out, anger may be another factor. The anger hypothesis was formulated in the days of Freudian psychology, according to Prof. Harder. It fell out of favor shortly thereafter, and has remained more or less unexplored until recently.
“When people squelch their anger [they] can essentially keep it unconscious, and aren’t really aware that they’re feeling it. It becomes clear after a while that they may be much angrier than they first think. And it’s usually anger at someone who’s important to them emotionally,” says Prof. Harder. “A lot of self-criticism, the low self-esteem, the sense of inadequacy, seems to be fueled and maintained by taking the anger and turning it inward.” This may be especially common in a society such as ours, where there is not much tolerance for anger or recourse for people who are feeling angry.
Another theory predicts that one’s conscious thoughts can create a depressive state — that is, by thinking pessimistically, the brain might alter its chemical physiology to match these thoughts, and in doing so trigger depression. Yet another theory suggests that emotions govern the cognitive function, so that, according to Prof. Harder, “if somebody suffers a terrible disappointment and feels badly about that, then they’ll start thinking pessimistically and their physiology will slow down and show…a lack of serotonin activation.”
There is a chicken-and-egg problem intrinsic to this: Which comes first? The emotions? The cognition? The chemical distributions in the brain? “We don’t have a final explanation,” says Dr. Harder.
Search and Destroy
This past October 17 brought with it the Tufts Counseling and Mental Health Service’s (CMHS) annual free Mental Health Screening Day (part of the National Depression Screening Day affiliated with the national College Response organization). Those who chose to attend — some fifty students this year — were welcomed with popcorn, a choice of body or foot massage, free goodies, and enough pamphlets to fill a library.
After completing a brief questionnaire about recent thoughts, habits, and feelings, participating students were then treated to a ten-minute consultation with one of Tufts’ staff therapists, who could recommend a course of action based on the questionnaire and a conversation. Even a person not suffering from depression would find the experience both reassuring and informative.
“Reassuring and informative” is exactly the image the Tufts health service is trying to project. Depression is a big, growing, problem on university campuses across the nation. Fortunately, depression is also a relatively easy ailment to treat. Through therapy, medication, or a combination thereof those suffering from depression can almost always be helped, according to NIMH. The difficulty lies in getting depressed students to come forth and seek help in the first place; the annual screening day is just one such program at Tufts that is designed to make that process a little easier.
Tufts mental health services sees about 1,000 students per year, not including outreach efforts. The American College Health Association estimates that every year, about one third of all college students suffer from depression so severe that “it is difficult to function” at least once in the year. For students on campus who are feeling depressed, Tufts counseling is ready: the provider to student ratio is actually higher than what is recommended by the International Association for the Accreditation of College Counseling Services.
So what happens when a student goes to CMHS for treatment? How does a person actually make the transition from depression to happiness? The main goal is to offer assessment, helping students identify the specific nature of their troubles. A student can go to health services and talk to a counselor, who can then help the student lay out the best course of action for dealing with his or her issue. In some cases, a student will have a problem that can be treated quickly, and in these cases CMHS will offer focus treatment — up to eight meetings tackling the crisis head-on. For those needing long-term services, the goal is to get the student stabilized at Tufts, then find off-campus resources to help them continue their treatment.
Ms. Jampel explains the role of a counselor during therapy: “What we try to do…is instill hope, and let them know that there are effective treatments, and that they don’t always have to suffer this way. We can help inform them about depression and what it looks like so they can recognize more of their depressed self for what it is.”
Drug Treatment Options
There are, of course, situations in which therapy doesn’t work, and it is in these situations that a student may be prescribed antidepressant medicine. Tufts has a prescribing clinician to handle this.
Antidepressant drugs are not without their controversies. On one hand, they often bring about positive results in patients much faster than therapy. However, various complaints have been leveled against them, ranging from claims of negative long-term side effects to questions about the ethics of changing a person’s mood.
According to Prof. Harder, “medication tends to be helpful in 70–75 percent of cases, but that is of course not everybody.” In the long run, he says, psychological interventions such as therapy may work better than medications, but (in the people for whom they’re going to work at all) drugs work faster. Therapy has the added advantage of giving a person a bit of resistance to future depressions. Therapy and medication can be used independently or in conjunction, at the discretion of the psychiatrist (or whichever clinician is treating the depressed person).
Controversies
The question every college was faced with in the wake of the Virginia Tech shootings was, “How do we prevent something like this from ever happening at our school?” Earlier this year, President Larry Bacow formed a committee to re-evaluate campus safety. One of the achievements of this committee was the Send Word Now program, which now has more than 15,000 subscribers who can be instantly notified by phone, text message and email in the event of an emergency.
Then there is the matter of identifying students who may be at risk for violence. Unless an applicant to the school supplies the information voluntarily, Tufts does not receive any information about the mental health or history of its applying students. Even if it did, to discriminate on the basis of this information would violate the Americans with Disabilities Act and the Rehabilitation Act.
According to Dickens Mathieu, the University counsel, the administration “is currently discussing background checks as a general subject matter, but no decisions have been made to change the current policy, which is not to conduct background checks on undergraduate applicants.”
Thus, the task of identifying a mentally unstable or potentially homicidal student falls onto his peers, professors, and mental health counselors. Of course, one of the problems in the Virginia Tech case was that the shooter didn’t have many friends, so there was nobody to notice signs of a worsening condition.
This problem is inherent to the college environment: Since students are away from friends, family, and others who have known them for a long time, abnormal behavior often goes unnoticed. For many, one of the joys of college is the lack of structure — fewer academic requirements than high school, more social freedom, and most importantly, no parents or principals breathing down your neck. But this lack of structure also makes it very easy for a person to slip between the cracks, avoiding normal social contact and being subject to self-perpetuating isolation.
What You Can Do
If you’re ever feeling depressed, the most important thing is to not blame yourself for not being able to “get over it.” Find someone to talk to. Tufts counseling and mental health services might be a good thing to look into. Says Julie Jampel, “The most important thing for people to know is that, we’re here — we truly are here, and that even if someone is depressed and recognizes it, even if we’re not the final stop we’re a very good first stop.” Occasionally, students feeling depressed will make their first visit with a friend — this is completely acceptable and often very helpful.