Stages of Depression

A Journey Through the Stages of Depression and Back Again

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Daily behaviors account for maintaining one’s health, both physically and emotionally.[1] Approximately 70% of morbidity and mortality can be attributed to five habits: how much we eat, what we eat, exercise, smoking, and alcohol intake.[2] Lifestyle is significantly and positively related to the quality of physical and mental health.[3] The chronic diseases that occur from choosing to eat too much processed food, being sedentary, smoking, and drinking excessive amounts of alcohol account for 75% of medical care costs.[4]

In terms of mental health, 27% of Americans suffer mental health symptoms and disorders that impact families, the workplace, and quality of life.[5] These commonly lead to overutilization of medical care.[6] Even though psychologists’ expertise resides in changing individuals’ lifestyle habits which are the ultimate causes of illness, mental health and physical health disorders continue to be treated differentially.[7] Only 24% of children and 35%-45% of adults with mental health problems have received any mental health services.[8]

Celeste is an example of a person with a mental health problem that is expressed physically. Yet a somatoform disorder does not make the physical complaints less real; both the physical and emotional aspects need to be addressed and treated. She is a 34-year-old married Caucasian woman with multiple physical complaints—fatigue, painful muscles, bloating, and lack of interest in the activities of her children (ages 12 and 15). She is having trouble sleeping and didn’t want anyone to touch her. She is disheveled, hair uncombed, no makeup, dark circles under her eyes, dressed casually in sweatpants, jacket, and muddy gym shoes.

When I asked her, “How long have you been depressed,” she replied, “Always.” She explained that depression runs in her family–her mother, grandmother, aunts. She added, “One of my uncles shot himself.” It was depressing just being around her.

She had tried various anti-depressive medications without success. She believed that once her physical problems were “fixed,” her depression would improve.

In an attempt to lessen the stigma of emotional problems, the cultural focus has been on the biological basis or “chemical imbalance of the brain” of depression or other mental health disorders. But this explanation is a double-edged sword, giving those with depression, anxiety, even schizophrenia a belief that medication is the only answer and if it doesn’t work, the afflicted have to live with it.

From my experience, depression is progressive and treatable. There are three stages: Helpless, Hopeless, and Hapless. A combination of anti-depressive medication and psychotherapy has the potential to stop the progression at any of these three stages.

Helpless: Depression begins early in a person’s life in a situation where the child feels helpless, powerless without protection. Celeste grew up with an alcoholic father who was unpredictable and violent at times. She tried to become invisible when he was home. Her mother was unable to protect herself, much less her daughter.
At school, she too felt helpless, afraid that classmates would ridicule her. She tried to fade into the woodwork. She had few friends and was on guard for those who may harm her. She considered herself a target for bullies. In high school, she discovered that she was good at math and science and found energy in excelling. She joined a group of friends with similar interests and felt accomplished.

Hopeless: In college, she was attacked by a young man she had been dating. This trauma pushed her into the hopeless stage of depression, where she despaired of creating a positive life for herself. She dropped out of school and worked at a fast food restaurant. She anticipated failure and expected the worse, which was usually the case. She became pregnant and married before she realized her husband was much like her father– moody, argumentative, and a heavy drinker. He joined the Army and was deployed during most of their marriage. She and her children lived on various military bases where she functioned as a single Mom.

Hapless: When her husband left the military, he functioned as head of the family in the same way he managed his squadron—strict discipline, unquestioning obedience, and intolerant of individuality. The children rebelled and Celeste fell into the hapless stage of depression where she saw her life as wretched. The entire family was miserable and inconsolable. Despite much effort, she could not bring together her children and husband. They became strangers that she no longer wanted to be around. She developed various physical complaints that expressed her emotional angst.

Unraveling the Stages of Depression

Helping her turn around her life is a complicated process, involving much more than 15-minute office visits. She needs an astute therapist who will help her unravel these stages and introduce alternative ways to cope with life. The therapist collaborates with the medical healthcare provider, reporting the effectiveness of medication and progress in psychotherapy.

The first step is to help Celeste practice behaviors that give her a sense of power. This may be as simple as taking time to exercise or joining a yoga class. This gets her out of the house, where she can breathe in fresh air, and see the world from a different, less fearful perspective. As she moves her body, the physical aches and pains lessen and she faces the prospect of becoming healthier.

Because pain is a major stressor, thermal biofeedback too is a tool to gain control over a body that seems to be on a downward spiral. Using soothing music or a visualization CD, Celeste can warm her finger temperature to 96 degrees, which is a measure of relaxation that transports her to a state of well-being.

The second step in therapy is to instill hope in Celeste by having her create and seek a goal. She may want to return to school or volunteer at church, school, or hospital. She may develop a skill, such as fly fishing or crocheting. She may want to paint or write or sing in the church choir.

The third therapeutic step is to communicate with her family about her concern that her children may become as depressed as their mother was. Learning to say, “No,” when her family demands something that is unreasonable, is a beginning. Saying, “I feel (angry, sad, hurt, happy) when you say that to me,” is a way to teach the family how to discuss feelings rather than hold them inside to fester or act them out in disruptive behaviors. It also puts a stop to using words as weapons that hurt and put others on the defensive.

Celeste is now in marriage counseling with her husband. She is successfully taking anti-depressant medication and will probably continue to do so. She can talk to her children and help them make important decisions while at the same time giving them confidence that they can live their own lives within certain guidelines. She has discovered that depression is not a life sentence; that behaviors can alter destructive emotions; and that health is the result of both physical and mental well-being.

 

Kathleen Farmer, PsyD, Headache Care Center, Springfield, Missouri
Published on March 5, 2013

References

  1. Weisner TS. Ecocultural understanding of children’s developmental pathways. Hum Dev. 2002; 45:275-281.
  2. De Vol R, Bedrosian A. An Unhealthy America: The economic burden of chronic disease—charting a new course to save lives and increase productivity and economic growth. Los Angeles, CA: Milken Institute, 2007. http://www.milkeninstitute.org/pdf/ES_ResearchFindings.pdf
  3. Walsh R. Lifestyle and mental health. Am Psychol. 2011; 66: 579-592.
  4. Centers for Disease Control and Prevention. Behavioral Risk Factor Surveillance System: 2008 summary data quality report, 2009. ftp://ftp.cdc.gov/pub/Data/Brfss/2008_Summary_Data_Quality_Report.pdf. Accessed February 13, 2013.
  5. Kessler RC, Wang PS. The descriptive epidemiology of commonly occurring mental disorders in the United States. Annu Rev Public Health. 2008; 29:115-129.
  6. O’Donohue WT, Cucciare MA. Pathways to medical service utilization. J Clin Psychol Med Settings. 2005;12:185-197.
  7. Wang PS, Lane M, Olfson M, Pincus HA, Wells KB, Kessler RC. Twelve-month use of mental health services in the United States: Results from the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005;62:629-640.
  8. Goldstein RB, Olfson M, Martens EG, Wolk SI. Subjective unmet need for mental health services in depressed children grown up. Adm Policy Ment Health. 2006;33: 666-673.