The word “depression” is a term in common use, although the meaning people attach to and use for it does not correspond to its technical meaning. In everyday language, “depression” means sadness, melancholy. Depression, understood as an illness, is instead a set of manifestations involving inhibition and slowing of behavior, emotional responses, and the orientation and progression of thought, accompanied by a “negative” mood. A depressed person is not necessarily sad: at times they are apathetic and emotionally flat; at other times irritable and difficult to deal with; at still others distressed, worried, fearful, or simply lacking motivation and tired.
In the past, one common expression used to refer to depression was “nervous exhaustion.” Although imprecise, the term at least suggested the cerebral (nervous) nature of the illness and its derivation from a slowed functioning of certain centers (“exhaustion”). Regarding the nature of the illness, one of the most frequent questions concerns its causes. If someone is “exhausted,” what is the cause that triggered the depression?
It is often said that someone “falls into” depression, as though something pushes them into it, that is, as though there were an underlying cause that produces the depression. This actually happens only in some cases. Often, as episodes recur throughout a person’s life, the triggering factor becomes less and less important, or there is no specific trigger at all. Moreover, the tendency to identify a cause is a kind of cultural “habit” of ours, whereas the causes that are blamed are often nothing more than events that happen to everyone, or that would sooner or later have happened in an ordinary life: bereavements, the end of romantic relationships, financial difficulties, increasing responsibilities at work or within the family, illness affecting loved ones, and so on.
The term “reactive depression” should therefore be treated with caution, because it is primarily an interpretation and does not necessarily change the nature of the illness. It would be like distinguishing between fractures caused by falling to the ground and fractures caused by someone pushing us to the ground: fundamentally, they remain fractures.
A depressed person “without a cause” is therefore simply an ordinary depressed person. If there is a distinction to be made, it may concern vulnerability to depression, which is presumably greater when the illness occurs spontaneously than when it follows a series of negative life events.
Finally, it should be noted that the negative experiences reported as causes of depression may simply correspond to the person’s view of reality through the depressive filter that is inevitably present at that time. This filter is usually shaped by ideas of ruin, guilt, failure, and distrust in the possibility of a positive future.
Returning to the quality of mood, not all forms of depression revolve around a mood that is subjectively described as “sad.” This is especially true in older people or in individuals who do not express their feelings verbally (alexithymia). Their distress may instead be described as tiredness or expressed through concern about physical ailments, while family members report a state of apathy, withdrawal, and closure that the person themselves cannot better characterize. This is sometimes referred to as “masked depression.”
Two main subtypes are usually distinguished, “typical” and “atypical,” or, more precisely, “retarded” and “lethargic.” In the “retarded” type, there is an inhibition of certain functions, beginning with speech, movement, facial expression, and speed of thought, together with a reduced ability to respond to external stimuli, resulting in a depressive “flattening.” The person often neither laughs nor cries, and tends to show little emotional vitality. Sleep is reduced, fragmented, and superficial; instinctual drives decline; there is weight loss and a kind of depressive isolation. In other words, the person tends to “sink” into the depression, believing that there is no choice or solution, and therefore makes little effort to seek treatment or medical help.
The “lethargic” form, on the other hand, resembles more closely a “depressive reaction,” in the sense that the person remains responsive to external stimuli, which may temporarily improve their mood, and continues to seek pleasure, although in a more passive and sluggish way (through eating, sex, even if solitary, or alcohol). Sleep is often increased, or the person sleeps simply to avoid thinking; appetite is preserved or increased. The person complains about the condition more openly and often adopts the attitude of someone waiting for a solution to come from outside (just as an animal in hibernation waits for a favorable season), avoiding commitments whenever possible, even though they are capable of carrying out normal activities when circumstances physically require them to do so.
The atypical form, despite its name, is therefore the more “normal” one when compared with the usual pattern of reaction to sadness, bereavement, disappointment, and so on. The other form is already more abnormal even in its milder stages and, when it becomes more severe, may be accompanied by a genuine disruption of judgment: the person’s ideas become expressions of a depressive state that goes beyond reality or common sense. The person may claim to be responsible for imaginary faults or for events for which they are not responsible, predict bereavements and disasters occurring because of them, claim to be bankrupt and to have no food or roof over their head, or believe that they have incurable illnesses. In the most severe forms, delusions of damnation or nonexistence may appear (believing that one is already dead, that parts of the body no longer exist, or that one can no longer breathe or move). These forms carry a high degree of risk and require urgent treatment.
The most insidious depressive condition, although not the most severe in terms of symptom intensity, is dysthymia, that is, prolonged minor depression. People with this disorder become accustomed to living in a depressed state, partly because they are still able to carry on with some aspects of their lives, albeit with difficulty, and partly because they attribute their condition to external factors that do not change and therefore keep them demoralized. Dysthymia becomes a kind of new personality or new mental state, unpleasant but experienced as by now inevitable People suffering from dysthymia may experience life as a kind of sentence to be served: they are able to accomplish various things, but with an effort that ultimately prevents them from enjoying them, both before and after. One might say that while a depressed person feels blocked and sees no way out when the depression is at its peak, a person with dysthymia, in their own way, cannot really be described as blocked, but neither can they see a direction that would truly be worth pursuing. In both cases, it is the depressive state of mind that produces this pessimistic view of reality, to a greater or lesser degree, but with essentially the same underlying quality.
As with any alteration in the functioning of an organ or organic system, depression can also progress from simple “slowing” to what is known as psychomotor “arrest”: the person does not move, remains mute, responds with gestures while keeping their eyes closed, no longer perceives the physiological urges to urinate or defecate, and does not eat.
Depression is also a provisional diagnosis. “Depressive Episode” is therefore not the definitive name of a disease, but the name given to that particular state during that particular period. There are several psychiatric disorders that consist partly or predominantly of depressive episodes, without necessarily resembling one another in their other symptoms or in their course. Recurrent Major Depressive Disorder is characterized by Depressive Episodes, as is Bipolar Disorder. Anxiety disorders can evolve into depression, especially over time if left untreated, while a neurological disease or a psychotic disorder may also initially present with depression.
It is not necessarily the case that the illness the physician sees during a depressive episode actually began with depressive symptoms. In Bipolar Disorder, for example, the periods preceding depression or occurring between episodes often include attenuated phases of euphoria or excitement that are not reported as part of the problem because they correspond to a vigorous, energetic mood. They are nevertheless an important element in distinguishing Depression from Bipolar Disorder. In other cases, the depressive period is preceded by long periods in which the predominant, or even only, symptoms are physical (intestinal symptoms, for example, such as those occurring in irritable bowel syndrome), or vegetative (insomnia, perhaps the most frequent precursor of depression).
At the time of diagnosis, therefore, the term “depression” is not sufficient to understand what type of illness is involved, and being sad is not the most important element in defining the disorder, but only one of its symptoms. Knowing what type of depression a person has, and whether the illness that emerges over time is fundamentally depressive or not, leads to a different diagnosis and therefore to a different long-term treatment plan. Among antidepressants, some, although older, remain particularly specific and effective for the retarded forms, whereas others are better suited to the lethargic forms. Drugs labeled as “antidepressants,” moreover, may not, for example, be the best choice in bipolar forms. Finally, certain symptoms, such as impulsivity or aggression, which may improve in the short term, can instead become unstable over the long term depending on the underlying diagnosis.