Understanding the different types of depression

Feeling depressed at times is part of being human. The famous British psychoanalyst Donald Winnicott saw the capacity to be able to sustain depressed feelings instead of suppressing them as a strength. However, intense or chronic depression is a sign that something is wrong.

What is depression?

People tend to think of depression as depressed feelings; lowness, emptiness, hopelessness or despair, which Churchill called his “black dog”. Low feeling (dysphoria) is a most recognisable feature of depression, although it is possible to be depressed without realising it.  

Sadness is a normal healthy emotion and different from depression. Depression is more crushing to the spirit. Having said that, some people are so afraid of becoming sad, that they block it or distract themselves from it. People can be afraid of falling into a deep well of sadness which will be too painful to bear or impossible to escape from. Avoiding deep sadness may work for some people, but it can cause depression if it is continually being evaded. Sadness is usually connected with loss; loss of a loved one, a relationship that has gone wrong, or some other aspect of life that causes great disappointment. People can be sad at wasted years of their life when they should have had more enjoyment, the absence of love, or the loss of a hope or dream that can never be. In therapy, it is important to get in touch with sadness if it's there, gradually if it's painful, and mourn the loss of whatever it is that the sadness is connected with.  

Depression: Diagnostically speaking, depression is measured by the number and severity of symptoms. In addition to feelings of low mood, other symptoms include poor concentration, lack of motivation and loss of pleasure. There are also “biological symptoms”; poor sleep such as early morning waking, or oversleeping, poor appetite or overeating and lack of interest or pleasure in sex. Furthermore, low mood, hopelessness about the future and despair are likely to be the hardest to bear.

Fluctuating mood: Some people have rapidly changing moods, feeling good one minute, terrible the next, at other times, irritable, angry, empty or depressed and often constant anxiety. When combined with unstable relationships and self-destructive behaviour, this may reflect an underlying personality disorder of the unstable or borderline type. Self-destructive behaviour covers a wide range, which includes drinking too much, using drugs, cutting the skin, impulsivity and risk taking. If this has been the case for many years, a blight to life, a longer therapy may be needed to overcome deep-seated problems. 

Bipolar affective disorder/manic depression: We can all be manic at times, but some people have more extreme periods of mania, when they become overactive, elated and even deluded about their achievements. Periods of elation alternating with periods of depression may be a sign of bipolar affective disorder, for which medication can be effective.

Unipolar depression: An extended period of depression with some of the biological symptoms described above.

Causes of depression: The American psychoanalyst, Jonathan Shedler described depression as analogous to a fever, in that the same symptom can have different causes. Vulnerability to depression is often associated with adverse experiences during childhood such as emotional neglect, physical neglect or abuse, affecting the growing child in their development, but a recent survey of research in the field (Nelson and colleagues, British Journal of Psychiatry, 2017) found that over half people who have depression have not had these experiences.

Examples of causes of depression include:  

• Significant social factors such as lack of job, money, social isolation and physical illness.
• A difficult life situation that the person feels responsible for, or powerless to change, for example a problematic relationship.
• Unexpressed grief in someone who has suffered a major loss such as a bereavement or end of a relationship and for some reason has not done enough mourning. This can sometimes be caused by complex feelings towards the person who is lost.
• Suppressed rage and anger turned inwards against the self in the form of self-criticism, instead of being expressed towards its true object. Many people have difficulty expressing anger or rage, feeling those feelings to be unreasonable or unproductive. When something everyday triggers anger or irritation, they must immediately suppress it, and some people do this by redirecting the anger at themselves, attacking by criticising themselves, and this can create depression. 
• Depression can also be caused by the life not being what it should be, for example, problems in one of the four key areas of life satisfaction; friendships/social interaction, work/career, love/sex, or an overall impoverishment and narrowness of experience. 

In psychodynamic psychotherapy we try to track down the current cause of the depression in the context of the whole person, including important experiences in their life such as their childhood. In cognitive behavioural therapy (CBT), the therapist addresses the symptoms more directly without looking at underlying emotions. People vary as to which approach they would prefer. It is not uncommon to try CBT first and if it does not work, have psychodynamic therapy. Sometimes therapy can resolve therapy depression, whilst for others, the patient may continue to have depression but it is less severe and more bearable. For advice on choosing a therapist, see my article on this site.