Depression is one of those names that we hear about frequently and is often part of our common language, yet there is still an immense amount of mystery around it. Some ideas floating around explain it as a brain sickness or a chemical imbalance. Others may say it’s a mindset. These ideas have reason for existing, and none are completely false, but it is not the whole picture, either. Sometimes, not having the whole picture can cause damage such as incorrect judgements or unrealistic expectations that lead to disappointment and frustration.

For example, viewing depression as a brain disease is partially accurate in that it is true that depressed people have diminished brain function and imbalanced hormones. Depression has a physical manifestation that cannot simply be wished away overnight.

However, the inaccurate aspect of viewing depression as a brain disease is that it infers that something physical has caused the depressed mood, like a body malfunction. It also infers that physical treatments like medication would be the most appropriate and maybe even the only appropriate treatment for depression. Although anti-depressants do help, they do not encompass the whole problem. Medication treats symptoms by lessening the strength of the emotion and reducing “stuck-ness,” but there are other factors keeping the depression alive, such as negative beliefs and thoughts. These we can control if we become aware of them and challenge them.

Many people become discouraged in the process of trying to manage their thoughts for a few reasons. I will address three of them:

1. Hopelessness. It is hard to believe that a solution exists and that things can change. Hopelessness is a symptom of depression, so it manifests physically and mentally.
2. Over-correcting thoughts. Often when people try to “look on the bright side” it turns into unbelievable or untrue statements, such as “everything is fine” or “I shouldn’t feel this way because I have a lot to be thankful for.”
3. Trying to change the results rather than the process that creates it. When people try to change their thoughts and beliefs, it is common that they often want to change much more than that (I will explain below), which is unrealistic, which contributes to that feeling of hopelessness.

So, what to do?

Depression Defined

According to the DSM-5 TR, depression, or Major Depressive Disorder (MDD) is characterized as:

A. Five (or more) of the following symptoms that have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure.

1. Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad, empty, hopeless) or observation made by others (e.g., appears tearful). (Note: In children and adolescents, can be irritable mood.)
2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation).
3. Significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. (Note: In children, consider failure to make expected weight gain.)
4. Insomnia or hypersomnia nearly every day.
5. Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down).
6. Fatigue or loss of energy nearly every day.
7. Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick).
8. Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others).
9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.

B. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
C. The episode is not attributable to the physiological effects of a substance or another medical condition.

Depression is an emotional and physical condition. The DSM describes observable behavior, but much more is going on. Brain scans have shown lower brain activation in areas used for memory, problem-solving, and decision-making, while there is higher activation in the emotional areas of the brain, such as the amygdala (which manages the fight-or-flight response)(Zhao et al., 2020).

Although brain imaging does show the physical components of depression, this does not indicate that the brain looks like this throughout time. This picture is a single moment of someone’s life. Brains change and adapt. When a person looks at a picture of a puppy, their brain activates in different ways than when they look at a picture of a violent scene. This is also true for thoughts. Thinking “I will never be happy” creates neural pathways and hormones that are different from when someone says “I am unhappy right now, but I am doing my best and things often change.” So, we have influence over how our brains work and what our PET scans might look like!

Before this begins to sound too easy, though, I will say here that thoughts are often habits. Humans don’t use critical thinking very often. Most of our thoughts are automatic ways we have learned to cope with something or survive. Thoughts form physical pathways– ruts– in our brains. This means that if you want to change a thought that already has developed into a mental highway, you will have to fight with it because the easiest thing to do is keep it automatic. It takes awareness and repetition to build a new mental highway, but it is possible, and our brains do it all the time when our situations change! I will talk about this more below when I explain CBT.

So, as can be seen here, depression is a real thing, and it is hard to work on getting better when there are symptoms such as “hopelessness,” “fatigue” and “inability to concentrate.” Plus, knowing that these symptoms are held in place by physical brain connections can make the task feel overwhelming. This is why it is important for those suffering from these symptoms to ask for help in order to stay motivated, focused, and accountable. You don’t have to use only one brain to overcome these problems!

How is it Treated?

There are currently a variety of treatments for depression, and new ones are being developed all the time. Cognitive-behavioral therapy (CBT), exercise, and anti-depressants are the most common effective treatments, and have proven their success with depression. It is not obvious which of these three treatments are most effective. Exercise, anti-depressants, and therapy are debated but often considered equal in effectiveness. Another newer wave of treatments that are promising are somatic treatments such as electroconvulsive therapy (ECT) and vagal nerve stimulation (VNS) (Nemeroff, 2020).

However, since I’m a therapist, I’m going to talk about CBT.

This therapy entails identifying negative thoughts or beliefs and replacing them with more accurate and helpful thoughts. When the thoughts change, so do the emotions that they inspire, which changes the direction of your neural connections and what hormones release.

As I mentioned earlier, often when people intuitively try to do this themselves they either deny their own hardship altogether (creating a lie) or try to control more than their thoughts and beliefs, such as their emotions or invasive memories.

Our depressed brains are way better at catching lies when they are positive rather than negative. If you are feeling sad and you say “I’m not sad, I’m having a great day” your brain knows you aren’t being honest, in which case, your emotions stay where they are, which is sad. If you say “I am not worth love like other people are,” that is a lie, yet because you are already sad it is easy to believe it, even though it isn’t logic that makes you believe it. Both examples are lies, but the negative one matches the vibe so it is easier to believe.

How To Change A Thought

Can you identify a depressing and illogical thought? In order to change a thought correctly, you first need to be able to notice which ones are causing damage and contributing to hopelessness. “I will never be happy.” This thought isn’t logical because you have no idea what the future brings, and it also tells your brain that there is no point in trying, which becomes a self-fulfilling prophecy.

Once you identify your depressed thought, you’ll want to see what about it can become more accurate and even hopeful. You want to make sure you are being honest, but also merciful on yourself. For example, if you are feeling sad, you might say, “I am sad right now, but I hope tomorrow will be better.” This thought may feel vulnerable because you fear it won’t be better tomorrow, but also, any hope at all would make one feel that way, so it is the only way forward. In the end, this statement is honest and not in denial, while also being reasonably optimistic. Subtle changes like these can make a big difference if you can get yourself to continually correct your thoughts whenever you notice them.

A note here: the automatic thought is OKAY! If you automatically think you aren’t worth love, that’s okay! Notice it, then consider what edits you can make. Automatic thoughts are going to happen and you won’t have control over that first thought. You have control over the second one.

The last thing I will address is the struggle some people have with trying to control more than just their thoughts. They want to will their emotions into being different, their memories to not come up, and their initial automatic thoughts to be different. Here I will introduce a diagram:

In this iceberg, you can see at the top, in our consciousness, are thoughts and perceptions. Literally EVERYTHING ELSE is unconscious or preconscious, meaning that we cannot directly control those things even if we wanted to. You cannot will yourself to be happy, or to not have fear, or be immediately different than you are. However, you CAN interpret those uncontrollable things in a way that ends up changing those things indirectly.

For example, if you are afraid of heights and you are on the edge of a cliff on a hike, your body will show signs of fear, and as the stress hormone cortisol is flooding your brain, your automatic thought will be “I’m going to fall!”

Now, at this point you can either believe yourself and allow that thought to go unchecked (you may not even notice it), or you can work on becoming conscious of that thought (which first may require some deep breathing and getting out of panic mode), and then decide to question that thought. “Am I really going to fall when the ground below me is flat? There’s also a railing that prevents falls. And no one has actually fallen here because there are barriers everywhere.” These thoughts, as you can imagine, will send completely different messages to the brain. The brain may realize it does not need to worry anymore, so the cortisol and adrenaline will slow down, and will leave more room for serotonin.

Developing these skills takes time, and usually you want to work on them outside of the perceived crisis so that you can be ready for when you do feel the worst. With repetition, it will become natural. It isn’t easy to overcome pre-existing hormones and neural pathways to want to say something different, but with gradually increasing awareness of what is going on with your brain it will feel less like the truth and more like a moment in time.

Depression (and anxiety, as with my example), have biological, emotional, and mental foundations, so don’t be frustrated if it takes time to see progress. The best thing I can recommend is to seek help if you need it, and to try to get slightly more aware of your automatic thoughts each day! Even thinking about thinking about what you have to do to feel better is progress, and it is the beginning of new neural connections!

References

American Psychiatric Association. (2022). Diagnostic and Statistical Manual of Mental Disorders, Text Revision Dsm-5-tr (5th ed.). Amer Psychiatric Pub Inc.

Kamil, M., & Abidin, S. Z. (2013). Unconscious human behavior at visceral level of emotional design. Procedia – Social and Behavioral Sciences, 105, 149–161. https://doi.org/10.1016/j.sbspro.2013.11.016

Nemeroff, C. B. (2020). The state of our understanding of the pathophysiology and optimal treatment of depression: glass half full or half empty? American Journal of Psychiatry, 177(8), 671–685. https://doi.org/10.1176/appi.ajp.2020.20060845

PET scan of the brain for depression. (2020, April 25). Mayo Clinic. https://www.mayoclinic.org/tests-procedures/pet-scan/multimedia/-pet-scan-of-the-brain-for-depression/img-20007400

Zhao, J., Jiang, W., Wang, X., Cai, Z., Liu, Z., & Liu, G. (2020). Exercise, brain plasticity, and depression. CNS Neuroscience & Therapeutics, 26(9), 885–895. https://doi.org/10.1111/cns.13385