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ADVANCE PRAISE FOR DEPRESSION: WHAT EVERYONE NEEDS TO
KNOW®

“For anyone seeking information about the nature of depression, why it happens, and how it
can be assessed and treated, this is your book. Even for those who already know a lot about
depression, the comprehensive up-to-date information and the beautiful writing style will
make this a bookshelf favorite.”
—Sheri L. Johnson, PhD, Professor of Psychology, Director, CALM
Program, University of California Berkeley

“This book is a must-read for anyone interested in and/or affected by depression. Written by
a foremost expert on depression theories and treatment, it combines the presentation of
cutting-edge knowledge with thoughtful and empathic descriptions of the main symptoms
and treatment approaches. The book not only provides important information, it also offers
hope and practical advice to people confronted with the disorder. It should be of great interest
to anyone interested in understanding and treating mental disorders.”
—Jutta Joormann, PhD, Professor of Psychology, Department of
Psychology, Yale University
DEPRESSION
WHAT EVERYONE NEEDS TO KNOW®

JONATHAN ROTTENBERG
Oxford University Press is a department of the University of Oxford. It furthers the University’s objective of excellence in
research, scholarship, and education by publishing worldwide. Oxford is a registered trade mark of Oxford University Press
in the UK and certain other countries.

“What Everyone Needs to Know” is a registered trademark of


Oxford University Press.

Published in the United States of America by Oxford University Press


198 Madison Avenue, New York, NY 10016, United States of America.

© Oxford University Press 2022

All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or
by any means, without the prior permission in writing of Oxford University Press, or as expressly permitted by law, by
license, or under terms agreed with the appropriate reproduction rights organization. Inquiries concerning reproduction
outside the scope of the above should be sent to the Rights Department, Oxford University Press, at the address above.

You must not circulate this work in any other form and you must impose this same condition on any acquirer.

Library of Congress Cataloging-in-Publication Data


Names: Rottenberg, Jonathan, author.
Title: Depression : what everyone needs to know / Jonathan Rottenberg.
Description: New York : Oxford University Press, 2022. |
Series: What everyone needs to know | Includes bibliographical
references and index.
Identifiers: LCCN 2020058294 (print) | LCCN 2020058295 (ebook) |
ISBN 9780190083144 (paperback) | ISBN 9780190083151 (hardback) |
ISBN 9780190083175 (epub) | ISBN 9780197586808
Subjects: LCSH: Depression, Mental. | Depression, Mental—
Treatment. | Mood (Psychology)
Classification: LCC RC537 .R6584 2021 (print) | LCC RC537 (ebook) |
DDC 616.85/27—dc23
LC record available at [Link]
LC ebook record available at [Link]
For Ollie and Cy
CONTENTS

ACKNOWLEDGMENTS

PART I: DEFINITIONS OF DEPRESSION

1. The Challenge of Defining Depression


What is depression?
How has depression been defined throughout history?

2. The Syndrome of Clinical Depression

What are the symptoms of depression?


How is clinical depression different from a sad mood?
How does clinical depression range in its severity?
What is the difference between unipolar depression and bipolar disorder?

3. When Should I Worry That I Might Be Depressed?

Case Study: Jose


Can I self-diagnose?
What are better ways to diagnose depression?

4. The Prevalence of Depression

How common is depression?


Is the prevalence of depression increasing?
A depression epidemic? Sorting out the evidence

5. The Consequences of Depression


How does depression impact mental and physical health, relationships, and careers?
Which mental health problems usually co-occur with depression?
Why does depression so often co-occur with other mental health problems?
Does depression ever have any positive consequences?

PART II: ORIGINS OF DEPRESSION AND THE DEPRESSION EPIDEMIC


6. Biological Contributions to Depression
Is depression a “chemical imbalance”?
Is depression due to bad genes?
What has research on the brain taught us about depression?

7. Environmental and Psychological Contributions to Depression

Is depression the result of stress?


Does depression stem from negative thoughts?
Does depression stem from relationship problems?
Can depression result from childhood events?

8. Depression Throughout the Life Course

Can children have depression?


Why does depression spike during adolescence?
Why are women more likely than men to have depression?
What is depression like in older people?

9. Depression Over Time

If I have depression, will it come back?


What is chronic depression?
Is there such a thing as a depressive personality?

10. Why Is There an Epidemic of Depression?


A mood science approach to the depression epidemic
How modern routines disturb mood
Does social media play a role?
The perils of a happiness-obsessed culture
Young persons: The future of the depression epidemic?

PART III: REMEDIES FOR DEPRESSION

11. What Are My Treatment Options?


What are the best treatments for depression?
Cognitive–behavioral therapy
Interpersonal psychotherapy
Medication treatments for depression
Other important treatment options
How effective are different depression treatments?
How should I decide which treatment to try?
How can I find a competent treating professional?
Final quick pep talk: Top five reasons to consider treatment

12. What Can the Depressed Person Do for Themself?


Start from where you are
Do self-help books help depression?
What about the role of exercise, sleep, or pets?
How can I discover my secret weapon against depression?

13. How to Talk About Depression and Help a Depressed Person


Why is depression so difficult to talk about?
Breaking down conversation barriers
What else can you do to help a friend or family member who is depressed?
When depression becomes a crisis

PART IV: LIFE AFTER DEPRESSION

14. What Is the Long-Term Prognosis for Depression?


Peering into the future
What is meant by terms such as recovery, response, or remission?
How common is full recovery from depression (and what explains why it happens)?
Can people flourish after depression?

15. Life After Depression


The first day of the rest of your life
Making sense of depression after it passes
What can be learned from depression?
Being prepared for relapse: Recommendations

16. Charting a New Future for Depression


What are the biggest remaining myths about depression?
What can the individual do to improve the conversation about depression?
How can the individual help bring about broader social changes that reduce the toll of
depression?
Is there really reason for hope?

RESOURCES
INDEX
ACKNOWLEDGMENTS

I express my gratitude to Sarah Harrington at Oxford University Press for her care and
support with the manuscript. Mary Kleinman helped greatly with research. Members of the
Mood and Emotion Laboratory provided early feedback on chapters. Rana Rottenberg
provided maternal care and copyediting. Laura Reiley provided nourishment of all kinds.
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PART I

DEFINITIONS OF DEPRESSION
1
THE CHALLENGE OF DEFINING DEPRESSION

What is depression?
A surprisingly difficult question.
Depression has spawned thousands of books. Yet one enduring view is that depression is
somehow beyond words (at least when we try to describe the experience). I believe that
launching more words (and even another book) about depression is not a futile or vain effort.
But let’s grant, the subject is full of paradoxes.
Depression is at once intensely private and the most public of problems. People who go
through depression are cut off from others, even as they experience symptoms that are shared
by millions.
Clinical depression is at once a pressing crisis—the World Health Organization deems it
the most burdensome global health problem—and a condition met with shrugs. Despite the
severity of the problem and the vast number of people affected, depression garners
surprisingly little public mobilization. People don’t march against depression or hold golf
tournaments or dance marathons to benefit those who suffer.
Another puzzle is that depression exerts the most visible of effects—the many calculable
losses tallied by epidemiologists and economists—be it lost work productivity and income,
broken marriages, or even deaths by suicide. And yet, at the same time, depression is also
invisible and incalculable. There is no test of blood, urine, or genes for depression. Those
affected have no obvious stigmata. There is no single telltale sign of the condition.
Then, there is the great imprecision in how people throw around the term depression.
Colloquially, the phrase “I’m so depressed” is said as a response to a multitude of everyday
disappointments—when rain spoils your picnic, when new couch gets coffee stained, when
concert tickets for your favorite band sell out. Such trivial uses of the term depression
suggest that depressed people must be whiners and complainers who exaggerate the severity
of their problem. Making matters worse, the same term, depression, is also used by
clinicians, scientists, and everyday people to mark the most catastrophic of states: when a
person is unable to get out of bed, unable to work, unable to self-care, and even consumed by
thoughts of suicide. When a single term is used to cover so much territory, widespread
confusion about what exactly depression is seems almost inevitable.
So, if we are to cut through the many misunderstandings that surround depression, we need
to simplify. Let’s begin with its incontrovertible essence: Depression is a kind of mood.
Within us all, we are endowed by evolution with a mood system. This system responds to
threats and opportunities in somewhat predictable ways. When we make quick progress
toward important life goals, our mood is usually good. When we are blocked in our progress
or move away from important life goals, our mood is low. Mood reflects the availability of
key resources in the environment, both external (e.g., food, allies, and potential mates) and
internal (e.g., fatigue, hormone levels, and adequacy of hydration), and ensures that any
animal does not waste precious time and energy on fruitless or even dangerous efforts, such
as doing a mating dance when predators are lurking. Given that resources of every sort—be
they time, energy, or money—are finite, expending resources on unreachable goals can be
ruinous.
The mood system is capable of great variety, from energized highs to everyday blahs to the
more severe moods we call clinical depression. The mood system has power over our minds
and bodies. Depression is the textbook demonstration of this power. Mood colors our
thinking: When we are depressed, thoughts turn to loss, failure, or incapacity. Mood biases
our actions: When depressed, we may withdraw, cancel plans, or give up entirely. Mood
states even influence our physiology. During depression, the body is aroused, locked in a
state of dread—night after night, sleep will be elusive.
The endowment of a capacity for mood inevitably brings with it the potential for both
good moods and bad moods, including the unpleasant mood states we call clinical
depression. It is likely that virtually everyone has at least some capacity for depression.
However, this does not mean that depression is the same for everyone. On the contrary,
depression affects different people in different ways. It has many different faces. For some,
depression may come out more as a disturbance in thinking; for others, bodily symptoms and
motivational changes might be most prominent; for others still, painful emotions are the focal
point. Depression may feel wrong or uncomfortable, but there’s not a right or a wrong way to
be depressed. Depression will likely mean different things to the tycoon on his yacht, the
homeless woman living under the bridge, the insurance salesman, or the fashion model, with
each appreciating their moods through the prism of their own life history and self-
understanding.
Saying depression is a mood and part of a larger mood system orients us. Being oriented is
the first step to helping us think more deeply about what depression is and where it comes
from. Much complexity remains. As we will see in the coming pages, many different forces
act upon the mood system. These include forces we’re aware of, such as environmental
events, the health of our relationships, our diet, sleep habits, physical activity, light exposure,
as well as our own thoughts. But the mood system is also acted upon by unseen forces—
forces of which we are not aware—such as the operations of our immune system or stress
hormones. Both seen and unseen forces act on the mood system simultaneously. This fact
almost guarantees that humans will face a degree of uncertainty about why they are
depressed.
This book takes our uncertain posture toward moods as both an assumption and a point of
departure for gaining a better understanding of depression. It is natural that the depressed
person wonders “Why me?” or “Why now?” and it can be frustrating to individuals or their
loved ones when there are no obvious “answers” to these questions. Nevertheless, it is
possible to become a more educated consumer of one’s own mood, and this book is intended
to provide help toward that end. This education includes how to know the difference between
depression and normal mood variation; how to better understand the forces that act on mood;
and how to better control those forces, including what individuals can do for themselves and
how to access additional help from professionals.
How has depression been defined throughout history?
Depression appears as one of the great perils of our times. We read stories about rising rates
of depression and commentary that connects it to contemporary trends such as increased use
of social media or the ways a gig economy negatively affects workers. The psychological
challenges of living amid the COVID-19 pandemic have also fed perceptions that depression
is rising in many countries, perhaps to unprecedented levels. Is depression a modern
condition?
A glance at history challenges the idea that depression is a malady of the moment.
Throughout the centuries, people may have varied in their beliefs about the causes of
depression, or what should be done about it, yet the actual descriptions of depression—its
key features and how it alters a person’s thoughts and behaviors—show remarkable
constancy. Something akin to our modern depression has existed throughout much of
recorded history.
Written accounts of a condition similar to what we now know as depression appeared in
the second millennium bc in Mesopotamia. One text described when a man had suffered a
long spell of misfortune,
he shakes with fear in his bedroom and his limbs have become weak to an extreme degree; if he is filled with anger
against god and king; and if he is sometimes so frightened that he cannot sleep by day or night and constantly sees
disturbing dreams; if he is weak [from] not having enough food and drink; and if [in speech] he forgets the word which
he is trying to say; then the anger of [his] god and goddess is upon him.

In these writings, depression was discussed as a spiritual rather than a physical problem (one
that might be caused by demonic possession). One did not call a doctor; rather, one needed to
hail a priest.
The ancient Greeks and Romans recognized melancholia, a condition that again appears
akin to modern depression. For example, in Orestes, Euripides depicts the tragedy’s
protagonist hounded by the furies after killing his mother. Orestes’ symptoms of depression
resemble those of any modern suburbanite: loss of appetite, excess sleeping, lack of
motivation to even bathe, constant weeping, chronic exhaustion, and a sense of helplessness.
Greek and Roman authorities on melancholia were split into different camps about its
causes. Hippocrates’ take on melancholia, or a condition of the “fears and despondencies, if
they last a long time,” was that it was a biological illness caused by an imbalance in four
body fluids called humors: yellow bile, black bile, phlegm, and blood. Specifically,
melancholia was attributed to an excess of black bile in the spleen. Hippocrates’ treatments of
choice to readjust the humors via bloodletting, baths, exercise, and diet. By contrast, Roman
philosopher and statesman, Cicero, took another view of melancholia, seeing its roots in
psychological events such as rage, fear, and grief. All the while, another great swath of
opinion continued to believe that melancholy and other mental disturbances were caused by
demons and by the anger of the gods.
In the Middle Ages, Christian religious views dominated European thinking on mental
illness. Mental health problems such as depression were largely a sign of God’s disfavor,
indicating a sinful life and/or a need for repentance. A sea change in thinking came with
Robert Burton’s 17th-century Anatomy of Melancholy. This widely read book offered a
variety of explanations of melancholy, including more secular, social, and psychological
reasons such as poverty, fear, and loneliness. Burton also included a number of nonreligious
recommendations for treating it, such as diet, exercise, travel, purgatives (to clear toxins from
the body), bloodletting, herbs, and music therapy. Even if depression cures such as purging or
leeches now seem foreign, Anatomy’s descriptions of melancholy accord with contemporary
psychiatry textbook descriptions of the psychology of the depressed person. Burton lays out
an episodic,
melancholy which goes and comes upon every small occasion of sorrow, need, sickness, trouble, fear, grief, passion, or
perturbation of the mind, any manner of care, discontent, or thought, which causes anguish, dulness, heaviness and
vexation of spirit, any ways opposite to pleasure, mirth, joy, delight, causing forwardness in us, or a dislike.1

In the 20th century, the contemporary term depression gradually came into wider use.
Many credit the pioneering 19th-century psychiatrist Emile Kraepelin for increasing the
popularity of the word, as well as for the view that depression was due to brain pathology,
which remains an important strand in mental health thinking to this day. At the same time,
new ideas from Freud and his acolytes viewed depression as resulting from intrapsychic
conflict (anger turned inward), a conflict that could be best addressed by talk therapy. To this
day, biological perspectives on depression continue to coexist with a variety of psychological
and psychosocial perspectives.
The 20th century also ushered in the more standardized diagnosis of depression that
currently prevails. As part of a larger effort to handle mental illness similarly to biological
diseases, psychologists and psychiatrists put together the first American Diagnostic and
Statistical Manual of Mental Disorders (DSM) in 1952. In this first manual, which has since
gone through several iterations, the term depressive reaction was used to describe a condition
of severe low mood resulting from an internal conflict or an identifiable event such as job
loss or divorce. In the DSM’s current incarnation, the principal place where depression is
discussed is the syndrome major depressive disorder, which will become familiar later in this
book.
Obviously, a Roman soldier, a Greek philosopher, a French peasant, and a New York City
cabbie might have very different reasons for becoming depressed. And the authorities of the
day would likely offer very different ideas about what each of these persons should do about
it, from baths to bloodletting, exorcism, and Prozac. But in another sense, no matter where
we turn in history, depression is depression. Each historical personage would likely
experience similar symptoms and behave in similar ways, despite the wide gulfs of culture
and language between them.
It is important to bear in mind that the evolutionary forces that sculpted our mood system
move at a glacial, geologic pace. Evolutionary change is much slower than the pace of
human events. Our world of airplanes, computers, and electricity presents us with an
unimaginably different physical and psychological environment from what the first Homo
sapiens faced 300,000 years ago, yet the nervous system that generates mood is basically the
same as that of early H. sapiens. Because the architecture of our mood system cannot keep up
with the furious pace of human events, different historical periods will trigger different
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Formula: [Mathematical expression or equation]
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• Interdisciplinary approaches
- Sub-point: Additional details and explanations
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[Figure 48: Diagram/Chart/Graph]
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Definition: Learning outcomes and objectives
• Statistical analysis and interpretation
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
[Figure 51: Diagram/Chart/Graph]
Important: Problem-solving strategies and techniques
• Ethical considerations and implications
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
Example 52: Current trends and future directions
• Key terms and definitions
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Key Concept: Learning outcomes and objectives
• Key terms and definitions
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Example 54: Literature review and discussion
• Comparative analysis and synthesis
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
[Figure 55: Diagram/Chart/Graph]
Practice Problem 55: Learning outcomes and objectives
• Experimental procedures and results
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
[Figure 56: Diagram/Chart/Graph]
Practice Problem 56: Problem-solving strategies and techniques
• Current trends and future directions
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Example 57: Learning outcomes and objectives
• Problem-solving strategies and techniques
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Definition: Experimental procedures and results
• Statistical analysis and interpretation
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
Key Concept: Comparative analysis and synthesis
• Historical development and evolution
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
[Figure 60: Diagram/Chart/Graph]
Review 7: Key terms and definitions
Remember: Current trends and future directions
• Case studies and real-world applications
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
Practice Problem 61: Assessment criteria and rubrics
• Fundamental concepts and principles
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Definition: Assessment criteria and rubrics
• Learning outcomes and objectives
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Practice Problem 63: Assessment criteria and rubrics
• Ethical considerations and implications
- Sub-point: Additional details and explanations
- Example: Practical application scenario
Formula: [Mathematical expression or equation]
Practice Problem 64: Statistical analysis and interpretation
• Critical analysis and evaluation
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Example 65: Best practices and recommendations
• Practical applications and examples
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
Example 66: Research findings and conclusions
• Historical development and evolution
- Sub-point: Additional details and explanations
- Example: Practical application scenario
Definition: Problem-solving strategies and techniques
• Key terms and definitions
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Key Concept: Fundamental concepts and principles
• Key terms and definitions
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
[Figure 69: Diagram/Chart/Graph]
Key Concept: Practical applications and examples
• Theoretical framework and methodology
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
Section 8: Key terms and definitions
Example 70: Key terms and definitions
• Best practices and recommendations
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Example 71: Statistical analysis and interpretation
• Ethical considerations and implications
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
[Figure 72: Diagram/Chart/Graph]
Remember: Critical analysis and evaluation
• Research findings and conclusions
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Important: Problem-solving strategies and techniques
• Assessment criteria and rubrics
- Sub-point: Additional details and explanations
- Example: Practical application scenario
Example 74: Assessment criteria and rubrics
• Historical development and evolution
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
[Figure 75: Diagram/Chart/Graph]
Note: Practical applications and examples
• Theoretical framework and methodology
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Practice Problem 76: Learning outcomes and objectives
• Research findings and conclusions
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
Example 77: Critical analysis and evaluation
• Interdisciplinary approaches
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
Definition: Historical development and evolution
• Historical development and evolution
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Example 79: Problem-solving strategies and techniques
• Ethical considerations and implications
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Module 9: Historical development and evolution
Practice Problem 80: Literature review and discussion
• Experimental procedures and results
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
[Figure 81: Diagram/Chart/Graph]
Example 81: Fundamental concepts and principles
• Interdisciplinary approaches
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
[Figure 82: Diagram/Chart/Graph]
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