“AND THE CAUSE OF DEPRESSION GOES TO…”: UNDERSTANDING THE MANY FACTORS BEHIND DEPRESSIVE DISORDERS

In clinical practice, I sometimes find myself wondering whether the word "depression" wouldn't be better explained if written in the plural: "depressions."

For one thing, because people who share the same diagnosis can present pictures so different that, at first glance, it seems hard to fit them under a single category. In some — the more "classic" cases, so to speak — sadness, hopelessness, guilt, emptiness, and loss of energy predominate. In others, what stands out is the inability to feel pleasure, irritability, anxiety, sleeping too much or too little, changes in appetite, fatigue, withdrawal, aches throughout the body, or a kind of fog that turns even the simplest decisions into a disproportionate effort.

There are, of course, classifications and specifiers that attempt to organize this diversity: major depressive disorder, persistent depressive disorder — formerly known as dysthymia — episodes with melancholic or atypical features, and depressive episodes occurring in the context of bipolar disorder, among other possibilities. Even so, people placed in the very same diagnostic category can live through remarkably different experiences. And express them in remarkably different ways, too.

But although this heterogeneity of depressive signs and symptoms deserves attention, it isn't exactly what I'd like to devote this post to — the post you're doing me the honor of reading at this very moment.

The word depression also seems to call readily for its plural when we consider its etiology. In medicine and the health sciences, etiology is the study of the causes, mechanisms, and conditions involved in the emergence of a disease or disorder. And in the case of depression, we almost never find a single, clean, isolatable origin.

Among the factors that turn up in the literature and in the stories gathered in my office are inborn traits of temperament, very early life experiences, traumas, the people we live among, exhausting work that feels barely valued, pain, sleep deprivation, growing old amid every imaginable form of deprivation — and a nearly endless list of other variables.

Honestly, faced with a list like that, it's hard to resist speaking of "depressions," plural and all. Which complicates the choice of which nominee will take home the Academy's prize.

A shared award

The ceremony works like this: there are several contenders in a given category and, in the end, only one is supposed to walk up on stage. In the popular imagination, depression tends to be explained much the same way: there must always be one main cause, a single winner, an answer capable of "closing" the case. And so, "the cause of my depression goes to..." genetics? Childhood? The marriage that ended? The job that's eating me alive? Hormones? My brain? Loneliness?

In real life, most likely none of these nominees climbs on stage alone. More likely they share the statuette, crowding around the same microphone, each one acknowledging its share of the work.

Clinical reality is rarely organized like a detective story, with a single culprit unmasked at the end. What I find is a kind of co-authorship among factors: a biological predisposition that lay silent until a loss awakened it; a difficult childhood that had been reasonably worked through until a trauma consumed the last emotional resources available; a chronically ailing body that began to collect on everything the person had been trying to ignore until then.

The causes, when we manage to identify them at all, almost always arrive in a pack — and they don't always wear name tags.

Fire pit, spark, and fuel

One helpful way to make sense of this multiplicity is to distinguish among predisposing, precipitating, and perpetuating factors. The division isn't perfect, but it helps organize the conversation.

Predisposing factors make up the ground on which a depression can take root. They include genetics, temperament, early experiences, trauma, learned ways of handling emotions, medical conditions, and other elements capable of increasing a person's vulnerability. Vulnerability, however, is not destiny. Genetic load and a turbulent upbringing predict depression about as unreliably as a loving home and an easy life rule it out. No one is entirely immune to psychological suffering, and no one is inexorably condemned to it.

Precipitating factors would be the spark: events that more directly precede the onset or worsening of a depressive episode — losses, separations, conflict, violence, illness, upheavals, the birth of a child, retirement, financial strain, professional overload, or anything demanding an intense period of adjustment.

Here, too, a situation that looks small from the outside can strike an exquisitely sensitive point in someone's history — just as, in the opposite direction, a person can come through a devastating life event without becoming depressed. Not because one is strong and the other weak. It simply means that similar events reverberate differently in people whose moments in life, personal histories, inner resources, and support networks are just as different.

Finally, there are the perpetuating factors: the ones that help keep the episode going once it has begun. The fuel that seems to burn forever once combustion starts. Isolation, for example, can be a consequence of depression, because the illness pulled the person away from the world of other people. What began as a symptom starts feeding the disorder itself. That's why the advice some people offer the depressed, however eager to help they may be ("you need to snap out of it," "just get out of the house," "try thinking positive"), tends to be useless. What looks simple from the outside is often precisely what the disorder has made even harder to do.

In some depressions — allow me to embrace the plural from here on — one specific factor may play a nearly starring role. In others, the process will seem to result from a gradual, almost invisible wearing-down: small renunciations repeated over and over, accumulated frustrations, relationships that offer little nourishment, lack of rest, a slow loss of purpose, unhealthy aging, or the feeling of living a life that no longer seems to belong to you. There won't necessarily be an explosion — sometimes there's only erosion.

And, finally, there may be cases in which no obvious triggering event can be identified at all. Depressions do not require a tragic backstory as proof of legitimacy.

Someone to blame

Patients often arrive at their appointments trying to conduct a kind of criminal investigation into their own history. Did she end up "this way" because of her mother, her ex-husband, the job she hates, the grandfather who passed "that thing" down to her father, who then passed it on to the children? It's legitimate to ask — of oneself and of others — in the attempt to understand what happened, to find meaning in the experience, to ease the guilt, and to guide treatment. The problem arises only when we believe that getting better is possible only after identifying a single, definitive, irrefutable cause.

The trouble is that the logic of the single cause implies the search for a defendant — and the nearest defendant may end up being the patient: "I was weak," "I let things get to this point." A multifactorial view can do the opposite, showing that the suffering resulted from a confluence of forces, many of them beyond individual control. From there, agency in the recovery process can arise from a more honest place, uncontaminated by the useless fantasy that falling ill was a personal choice.

By the same token, we must take care not to look at the causes of depressions in the opposite way, naming an endless roster of culprits. Understanding that someone else's possible role does not exempt the personal responsibility of those who cast themselves as victims brings the discussion back into the real world and opens up a horizon of possibilities whose realization no longer depends on whoever caused the suffering, but on whoever takes up the fight against it.

Is it all down to chemistry?

This is a question that, were it not for the very real suffering depressions cause, I would rather enjoy answering. At some point, the notion became popular that depression (in the singular) was caused by a "chemical imbalance" in the brain, translated as too little availability of a neurotransmitter called serotonin. The idea had a certain value in pulling depression out of the realm of weakness of character: if there was a biological dimension, then the patient wasn't simply choosing to feel that way. Much less faking it.

But we now know the nervous system doesn't work in such a linear fashion. Neurotransmitters do indeed take part in processes related to mood, sleep, motivation, appetite, anxiety, and many other functions. But depressions cannot be reduced to the isolated deficiency of a single molecule. Antidepressants do work — whether monoaminergic (improving the availability of one specific neurotransmitter), dual-action, multimodal, and so on. Biology is present, but biology itself is shaped by experience. And, in response, experience can "change" biology, so that the two feed into each other. If the word "multifactorial" just crossed your mind, you got it right. Psychotherapy, learning, and personal and environmental change also elicit biological transformations, because everything we live through is processed by one and the same living organism, in which the biological and the psychological are not separate dimensions. They are inseparable parts of a single being.

Same word, different solutions

If there are different depressions and different causal combinations, it seems only logical that treatment won't be the same for everyone. For some, pharmacological interventions will play a central role. For others, relational conflicts, trauma, grief, isolation, overload, or certain psychological patterns will demand special attention. That is, when a combination of strategies isn't needed outright.

Recognizing the complexity of the causes allows us to build a treatment more coherent with the consequences being felt.

Antidepressants — which can differ from one another as much as the causes of depressions themselves — can help restore the energy and flexibility needed to reorganize one's routine and get more out of psychotherapy. Psychotherapy, in turn, can help re-examine painful experiences, recognize patterns that set the stage for relapse, and build new ways of relating to oneself and to others — even of persuading oneself to stay on the medication.

We cannot erase our histories and rewrite them from scratch, or travel back in time, as in science-fiction movies, to prevent the loss that ended up changing our fate for the worse — nor can we swap out the genes we inherited. But we can transform the way we allow certain experiences to remain present, expand our resources for facing their aftermath, treat associated illnesses, build more secure bonds, and dismantle the conditions that do nothing but perpetuate suffering.

So who takes the statuette home?

At the end of this rather exhausting ceremony, perhaps the host opens the envelope, milks the suspense for a few seconds, and announces:

"And the cause of depression goes to... a singular combination of biological, psychological, social, and circumstantial factors, whose weight varies from person to person — and even between different episodes lived by the same person."

It's not a line that would fit easily inside a golden envelope opened on a gala night, but it's probably the closest answer to reality I can offer.

Whether the protagonists are few or many, treatment doesn't have to wait for them. We don't need to understand perfectly how a fire started before we begin putting it out. But knowing what feeds the flames certainly helps in choosing the next strategies for extinguishing them for good.

Thinking in terms of "depressions," in the plural, may help us avoid further fragmenting those who are already suffering — and keep profoundly different histories from being compressed into a single explanation. The diagnosis may well be the same, but each person who receives it, what brought them to it, and the road back will never be.

 

AI-generated image from a prompt by the author.