Dear Neurontic

I have some experience with depression, mostly mild although I have had a couple periods that could be described as major depressions. I know that my thoughts are intimately connected to my brain chemistry and that paying attention to how I'm thinking can alter my mood. For example, if I catch myself starting to feel depressed, I can pay attention to the conversations I'm having with myself and interrupt the thoughts that go something like "You worthless, useless, lazy slob". That, along with taking care of chores and projects I've been letting slide, and getting some exercise, usually help. But not always. Neurontic, can you explain what's going on when these remedial activities aren't working? Why am I sometimes powerless over depressive thoughts?

Got the Blues

>Dear Got the Blues,

First off, I think we need to make a clear distinction between a perfectly healthy dip in mood and clinical depression (major depressive disorder). We don't want to make the mistake of pathologizing sadness. Dark times are, after all, a normal part of life.

That said, if you are experiencing clinical depression, it's important to identify it, and here's link to the checklist psychiatrists use to diagnose depression: Symptoms of Depression.

If you find yourself experiencing some combination of these symptoms for longer than two weeks, I'd urge you to consult a doctor, not only because clinical depression can be so debilitating and painful, but also because it does a number on your brain.

Research has shown that prolonged clinical depression interrupts neurogenisis (the birth of new brain cells) in the hippocampus, a key player in memory storage. When depression goes untreated it can lead to shrinkage in the hippocampus, which causes memory impairment. Severe depression can also reduce activity in the frontal cortex (the logical/decision-making mind).

Put simply, chronic depression causes brain damage. But before you panic, know that Prozac has been shown to stimulate the growth of new brain cells in the hippocampus, and antidepressants as a whole, appear to restore normal functioning in the frontal cortex. In short, much of the damage caused by clinical depression is reversible if the illness is properly treated.

If you do find that you're suffering from clinical depression and are uncomfortable with the idea of artificially altering your brain chemistry, I'd suggest looking into cognitive behavioral therapy. To date, CBT is the only form of talk therapy to be clinically tested (although Nobel Laureate Eric Kandel and the Ellison Medical Foundation are in the process of studying the physical impact of other forms of talk therapy).

Studies have shown that, when effective, CBT also works to reverse the damage done by clinical depression. Emory University's Helen Mayberg (Much Ado About Area 25) conducted a study that showed that "cognitive behavior therapy is associated with a characteristic pattern of metabolic changes in the frontal cortex, cingulate, and hippocampus." (NeuroPsychiatryReviews) Put simply, this means CBT has the same results as antidepressants, though it works far more slowly.

All of which is a really round about way of getting to your central question: Why are there times when I can't talk myself out of depression?

The simple answer is that clinical depression hijacks your logical mind. If negative thoughts predominate for too long a feedback loop is established between the thinking mind (or frontal cortex) and your fear center (the limbic system). Negative thoughts continually trigger a flood of stress chemicals in the limbic system; these chemicals, in turn, trigger more negative thoughts. Ultimately, the thinking mind becomes so overwhelmed with trying to process painful feelings, it can do little else--hence reduced activity in the frontal cortex.

Helen Mayberg thinks she has identified the brain malfunction that keeps depressives stuck in this self-perpetuating cycle: area 25. (Much Ado About Area 25) Mayberg suspects that area 25 is the highway connecting the logical mind with the "feeling" mind. Area 25 has been shown to be hyperactive when people are in the grips of clinical depression. What does this mean? Essentially it means that during a major depressive episode, the emotional floodgates are left open for too long. Depressives are continually assaulted by painful feelings even when there appears to be no rational explanation for them.

Thankfully, this process can be interrupted. Antidepressants seem to work by catalyzing the production of the chemicals associated with "good feelings." This eventually results in an upsurge of "good thoughts," effectively restoring normal functioning in the frontal cortex (and the hippocampus). CBT appears to cause similar changes.

Deciding whether to use drugs or talk therapy (or some combination thereof) to treat your depression is a very personal choice. Obviously, if the depression was catalyzed by external events it's imperative that they be dealt with, and talk therapy is undoubtedly one of the most effective ways to do that. That said, severe depression can compromise our vision of ourselves and our lives, and using medication in conjunction with therapy has been shown to improve the odds of recovery.

Have a question for Neurontic? Email orlivan [at] gmail [dot] com.