I have found two basic ideas to be helpful in understanding depression: stress pileup and catch-22. We know that episodes of major depression are preceded by stressful events, and these events have two main themes: loss and failure. Loss of a key relationship through death, divorce or a break-up is a common precipitant of depression. A feeling of failure could be associated with not meeting your aspirations or others’ expectations at work or in school—or with relationship problems that also involve loss.
Often, depression is preceded by a cascading pileup of stress: problems at work lead to overuse of alcohol, which further impairs work performance; drinking to cope leads to marital conflict, which further fuels alcohol use; marital conflict is stressful for children, who then have more difficulty in school—such scenarios are innumerable.
“All the things you must do to recover from depression are made difficult by the symptoms of depression.”

Being Vulnerable

Although depression is commonly preceded by stress, many people manage a pileup of stress without becoming depressed. Why do some and not others succumb? One reason is genetic vulnerability to becoming depressed in the face of stress. In addition, general medical conditions and physical ill health can contribute to depression.
Yet another reason for vulnerability: a history of stress pileup over a person’s lifetime. Childhood trauma, such as loss, abuse and neglect—combined with genetic vulnerability—can contribute to risk for depression in adulthood. Stress and episodes of depression in adolescence also add to risk for later depression. And, as in the example given earlier, substance abuse is a catalyst for depression: if you’re headed into depression, substance abuse can speed up the process and hinder recovery.

Depression’s Impact

Depression notoriously saps energy and impairs concentration and complex problem-solving ability. Thus, heading into depression, you are liable to struggle harder to stay afloat, for example, in managing demanding jobs and household responsibilities, including caring for children or aging parents. Effort increases while energy decreases. At some point, you run out of energy entirely and “crash” into severe depression. It’s as if your mind wants to keep going but your body declares, “I quit.” At the extreme, you can become bedridden.
Adding insult to injury and contributing further to the pileup is the fact that many people feel ashamed of being depressed and withdraw from relationships as a result. Because social isolation is a major contributor to depression, more stress pileup ensues. Another potential blow: the prospect of stigma can interfere with seeking professional help.

The Catch-22

Paradoxically, the process of recovering from depression also is stressful in that it’s extremely challenging. I attribute this to a catch-22: all the things you must do to recover from depression are made difficult by the symptoms of depression: you should sleep well, eat well, be active, engage in pleasurable activities, think realistically, stay engaged with persons who can provide support and maintain hope.
Now consider the symptoms of depression: insomnia, poor appetite, lethargy, diminished capacity for pleasure, negative thinking, social withdrawal and hopelessness. Recovery is the norm, but the catch-22s often make this process of recovery slow—several months to recover fully from an episode of major depression is not unusual. (I talk a lot about the catch-22s of depression in my book Coping with Depression in case you’re interested in learning more about them.)

Tips on Recovery

Here are some key points for recovering from depression and preventing further episodes:
  1. See if you can find a way to get out of the maelstrom of stress pileup to take stock of your situation, respecting the power of the stresses without minimizing them. Psychotherapy can be helpful in such stock-taking; sometimes patients need the asylum provided by hospitalization to get the needed respite and distance from the stressful situation.
  2. At least in the short run, do everything humanly possible to minimize stress. This is not easy: you can’t give up your children or quit your job and go to the Bahamas. Yet you might find ways to cut back some. Saying “no” is not easy but can be helpful. Ditto for seeking help.
  3. Take stress seriously and develop methods of coping more effectively. In his masterful book, The End of Stress as We Know It, stress researcher Bruce McEwen asserted that everything we know about managing stress our grandmothers could have told us. But now we have the scientific evidence to back up grandmother’s wisdom. Sleep, diet, exercise, relaxation, pleasurable activities—these are the mainstays of stress management. Yet we must be mindful of the catch-22s.
  4. Be patient with yourself regarding any difficulty you may experience in recovering from depression. Patients who have recovered refer to the “baby steps” that got them there. Catch-22: being patient with yourself can be difficult because depression spawns self-criticism.
  5. Make every effort to stay connected: the mere presence of another person can ameliorate stress, and the presence of a trusted companion with whom you have an emotional bond is the most potent antidote to stress known to man (and to many other mammals).
  6. A caution: It is little wonder that depressed persons seek potent chemical solutions. Alcohol, for example, relieves anxiety and produces pleasure—all too temporarily. In the long run, as stated earlier, substance abuse catalyzes and prolongs episodes of depression. The worst time to drink or do drugs is when you are doing so to manage psychiatric symptoms of any sort.
There is one major basis for hope: the vast majority of depressed persons recover, albeit slowly. And to drive home the importance of others in a person’s recovery,  I conclude with this anecdote: when I made the point in an educational group that it is difficult but not impossible to recover from depression, a patient rightly protested: “Doc, I can tell you that it was impossible for me to recover on my own.”