The costs of depression on a variety of levels are huge: Marriages and families splinter, individuals suffer, societies suffer the consequences of the often destructive behaviors of people coping badly or not at all with their depression, businesses suffer the negative effects of employees too disabled to function properly, the economic costs of greater health care expenses are greater for depressed patients, and there is the tragedy of suicide – lives lost to despair and apathy. Depression is a terribly disabling disorder, and despite significant advances in treatment, the problem continues to grow.

Depression is a multi-dimensional disorder. It has biological components based in genetics, neurochemistry and physical health, it has psychological components that involve many individual factors such as cognitive style, coping style, and qualities of personal behavior. And, it has social components, factors that are mediated by the quality of one’s relationships, including such variables as the family and the culture one is socialized into, and one’s range of social skills. The best, most accurate answer to the basic question, “What causes depression?” is, “Many things.”

Currently, the medical model of depression receives the greatest attention for a variety of reasons. The pharmaceutical industry in particular has invested tens of billions of dollars in advertising to the public as well as investing directly in individual physicians, encouraging all to define depression as a disease caused by a neurochemical imbalance that requires medication to manage. The lion’s share of research money goes to drug research, further elevating drugs to the status of being the source of hope for everyone who suffers depression. As a result, antidepressants are the most widely prescribed medication in the U.S., and are considered a first-line treatment approach, de-emphasizing the value of psychotherapy despite its success not only in treatment, but in the area of prevention.

It may sound extreme to some, but I stand by this statement: Depression is more a social problem than a medical one, and no purely biological cure will be found for it any more than biology alone will cure other social ills such as poverty or child abuse. This is not to say that antidepressant medications shouldn’t be a part of treatment, especially in those specific instances where there are clear benefits medication can provide over psychotherapy. Rather, medications should be used more carefully and with an associated recommendation for a well-considered skill-building psychotherapy.

The social side of depression is especially important, yet is terribly under-considered in most people’s consideration. We know, for example, that depression runs in families: The child of a depressed parent is anywhere from three to six times more likely to become depressed than the child of a non-depressed parent. The genetics research makes it quite clear that it isn’t entirely – or even mostly – faulty genes responsible, especially since there is no “depression gene.” It has more to do with the patterns of thinking, coping, behaving, and relating that parents (and other significant role models in our society) model day in and day out than it does one’s genetic makeup. When you have the largest demographic group of depression sufferers now raising children, it should surprise no one that their children are the fastest growing group of depression sufferers. After all, parents can’t teach their children what they don’t know.

Furthermore, the more distressed one’s marriage, the more likely one is to either already be or to become depressed. The quality of one’s marriage is a very large risk factor, yet many people never consider how powerful a good marriage can be in helping insulate its members against depression. These points provide excellent reasons to want to strengthen parents and marriages.

To think of depression as only an individual’s biochemical disorder, as if he or she isn’t a product of powerful social forces that operate in families, organizations, and cultures, or to reduce it even further to a purely biochemical phenomenon, is so terribly reductionistic as to disempower the very people who need help changing their lives, not just their brain chemistry. It’s true: You are more than your biochemistry.

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A milestone was reached toward the end of last year, and the press made no note of it. In October, the World Health Organization declared that now, among all the illnesses and forms of injury it measures, “depression is the leading cause of years lost due to disability.”

I have a personal stake in this announcement. In doubting reviews, I was twitted for claiming in my 2005 book, Against Depression, that “depression is the major scourge of humankind.” This criticism was based on a misreading. What I had written was that the WHO and other organizations interested in public health were making that assertion. The full paragraph goes: “Groups around the world have undertaken the same effort using different assumptions and weightings. The results of these analyses are similar. Varied assumptions lead to a single conclusion: Not AIDS, not breast cancer, but depression is the major scourge of humankind.”

I went on to explain how the WHO assesses disability. It uses a measure, called “disability-adjusted life years,” or DALYs, that gauges how far a disease or injury robs a person of good health. If you live in a country where the life expectancy is 80 but cancer kills you at age 60, you have lost 20 good years; but likewise, if a birth injury partially paralyzes you and leaves you 25% disabled, then if you live to 80 you will also be judged to have lost 20 good years. Actually, the birth injury would be rated worse, because the measure values years in young adulthood slightly more than years in old age. Because major depression is so common and so severe in its effects, and because its onset is often early in life, it tends to stand out in surveys focused on DALYs.

I should add that the panels that devised the rating systems used by the WHO included few or no psychiatrists. Surgeons, pediatricians, and internists made the assessments. When the results of the first surveys emerged, the prominent place of depression surprised everyone. But the findings have been consistent over time. What has changed is largely the WHO’s willingness to stand behind them and emphasize, as it did in its recent the press releases, depression’s awful status. Still, here it is: the claim I was criticized for (but did not quite make) is now the official position of the preeminent authority on global health and illness.

The survey available when I was writing was based on 1990 data; the new report has updates from as recently as 2004. As had been predicted, depression has moved up in the standings – that is, it appears yet more disabling, compared to other conditions.

In truth, the status of depression has changed only modestly. Because they kill children at birth and so rob them of a whole life span, “lower respiratory infections” and “diarrhoeal diseases” remain at the top of the DALYs list. But those categories represent clusters of differing illnesses. Depression comes next, and it is arguably a narrower category.

If you set aside low-income countries and look either at middle- or high-income countries, depression is now absolutely atop the list, above ischemic heart disease and cerebrovascular disease, above traffic accidents, dementia, and diabetes. If you look regionally, here in the Americas, depression is also outright the most disabling condition, above violence and heart disease. For women, depression is the leading cause of disability everywhere, even in low- and middle-income countries, outpacing HIV/AIDS.

One can debate the WHO measures. They count each episode of depression as highly disabling; but then, they omit more minor episodes altogether. Also, they ignore links between conditions. For example, maternal depression is a potent risk factor for infantile diarrhea. Self-inflicted injuries, which are very common in poor countries, are counted as separate from depression. And really, wouldn’t depression be a serious enough problem if it were judged only as disabling as cancer, heart disease, diabetes, or AIDS? Still, the WHO Global Burden of Disease study is the gold standard, and it finds depression to be, yes, the severest scourge.

Regarding science journalism, we live in strange times. When isolated academics use esoteric studies and idiosyncratic theorizing to question depression’s standing as a disease, that’s news. But when the world’s leading public health organization, using a quite strict definition of illness, announces that depression has become the leading cause of disability in our hemisphere – you can scour the pages of the press and find nary a report.

Depression stinks. No doubt about it. Having treated dozens of individuals with depression over the years, while reading countless books on the treatment, I still believe that the number one factor that really enables me to get to the heart of this malady is my firsthand experience with it.

Depression started tugging at my heels by the time I was 8 years old. By 16, the dean of my high school would call me each morning to make sure I got out of bed and showed up at school, instead of sleeping all day. By 30, I had two boyfriends; Ben and Jerry. Today, I still have low moments, but they are far less often, and last far less long.

Imagine if we had a scribe in our heads, even for a day. I know I would be ashamed to think of what mine might write. Having done a great deal of research on depression, I have heard many expert opinions regarding its etymology. We are still unsure if it is environmental, historical, genetic, energetic, past-life, DNA-related, trauma-based, kharmic law. One thing is for sure; when we got it, we got it, and it can be crippling.

What folks may not know is that there are very useful tricks we can use to alleviate a sour mood. The brain is plastic. It is the last part of our body to really know something. When we tell our brain that life is awful and we are doomed, our brain tends to agree. In fact, I have noticed that when I experience a bout of depression, it is often triggered by events where I feel exposed as a failure. My way out usually begins with a decision. A decision to feel better.

So, I decided to compile this list. Write these down, stick em on your wall, and put them in motion.

Trick 1: Get out of your head and into your feet
The body craves movement. Exercise really works. Let’s not think of it as exercise though. Nothing is gnarlier to the depressed person than imagining him/herself at the gym in ill fitting sweats, panting on the stair master while svelte athletes are bopping around in all directions. As Woody Allen says, 90% of success is showing up. Once we’ve got our walking shoes on, once we get endorphins cooking, the doldrums have less power to penetrate.

Christine Caldwell, Body-Centered Psychotherapist and author of “Getting our Bodies Back” tells us: Our bodies love to move and must move. Movement is the way we define life–when our heart beats, lungs pulse, brain waves, we are alive; in the absence of movement we become inanimate or dead. When movement is held back, energy/life flow is impeded and we become sick.
Rating- 2
I enjoy walking.  Unfortunately it is raining 90% of the time in Washington and that doesn’t entice me to go outside.  We purchased a treadmill, but our dog uses it more than we do.  I know that I feel better when I exercise, but we don’t always do what we know is good for us!  =)

Trick 2: Turn on the music
Keep an arsenal of inspiring and fun music. When we’re depressed, the smallest task feels overwhelming. If I can kick-start someone’s joy, then I am thrilled. Turn on the sound.
Rating- 5
I grew up listening to my dad blast his classic Motown hits.  Our home was always filled with music.  When I actually remember to turn music on, I do notice that I feel more motivated.  We recently hooked up some speakers to the ipod and have been listening to more music.  Hopefully we can keep it up!

Trick 3: Sit in the sun
Many of us work in windowless cubicles or offices, and wonder why we feel blue. This time of year, when the sun sets earlier, we lose vitamin D. Do anything you can to take in more light. Sit in the sun for 5 minutes. And if there is no sun in your world, then buy a full-spectrum light. Get one cheap on E-bay.
Rating- 3
Oh- wouldn’t it be nice if there were actually sun to sit in!  In the warmer months my dog and I do go and find the warm patch coming through the window and curl up on a rug, but those months are a ways off.  I have a light that produces artificial sun, but I have not been using it.  We do have plans to start a light therapy regimen in the near future because I believe in the power of sun!

Trick 4: Hang out with 4-leggeds (Unless you’re allergic)
Having an animal companion near can instantly release oxytocin, that delicious hormone that we secrete when we fall in love, give birth, or are nursing. It releases a feeling of goodwill, or trust in the world. OK, so not all are blessed to be in love all the time, or be breast feeding, so find other ways to bring on the joy chemical. Read on.
Rating- 10
My dog is literally a lap dog.  As soon as anyone sits down and a “lap” is formed, she is on it.  This results in lots of oxytocin!  See my post on Dog Therapy for more of my thoughts on the benefits of animals.

Trick 5: Change your thoughts
We have around 60,000.00 thoughts per day. Some 87% of them are negative and are the same thoughts we had yesterday. Experiencing joy is a deliberate choice. Joy takes practice. Joy is hardcore.

In Natural Intelligence, Psychotherapist Susan Aposhyan states; “On a muscular level, any thought also results in at least minute muscular responses, evidencing the body’s compulsion to somehow do the thought. Having an affirmation, allows the mind to want to do the thing that we are hoping for.

We must remember that affirmations don’t make something happen, they make something welcome. People tell me, “I put an affirmation up on my bedroom wall, saying: “I am ready to meet a gorgeous, successful, fabulous man who will adore and worship me.” It’s been 3 months. Where is he?” I tell them; “You have made yourself more open to meeting this human. Finding him is another story. Sorry.”
Rating- 3
I am a pessimist.  I believe it is impossible to be a realist without being a pessimist.  Unfortunately pessimistic thought don’t bring warm fuzzy feelings with them.  I am married to the King of Optimism and am slowing learning how to control my thoughts.

Trick 6: Follow a joyous lifestyle.
Find a class, a workout, anything that gets you in your body, preferably sweating a bit. Just getting out of the house and being with other people, say, in a yoga class, or dance class, or knitting group, offers us a distraction from the mind chatter. It works.
Rating-2
I leave the house on average 2 times each week.  Once to go to church, and once to go grocery shopping and get gas.  Some weeks we don’t need groceries or gas, so I just go to church.  I’m still working on finding something enticing enough to get me to actually leave the house more often.

Trick 7: Affirm joy with words
Rudyard Kipling said “I am by calling a dealer in words. And words are by far the most powerful drug in the world”. It may seem trite, but changing the way we speak can be extremely influential in changing our moods.
Rating- 2
This ties directing in to Trick 5.  I first have to think positively before I can actually say positive things.  A work in progress…

Trick 8: Grab hold of a goal
Make it a do-able one. Psychologist Martin Selegman tells us: Happiness and joy come from goals. We mustn’t put off our lives.
Rating- 4
I am really good at thinking of goals.  I am really bad at actually following through.

Trick 9: A smidgen of faith
Christiane Northrup, bestselling author of Womens’ Bodies, Womens Wisdom, and expert on mood disorders, shared this pearl of wisdom in a talk that she gave last summer at the Omega Institute. She says; “We are whom our higher self wanted to experience.” There is some truth to the pithy phrase: There’s no aetheists in foxholes. Have a smidgen of faith and the world can be a gentler space.
Rating- 9
I am religious and believe that we are given trials from a loving Heavenly Father to help us learn and grow.  I also believe that with His help all things are possible.

Trick 10: Choose joyous companions
When we are depressed, we take our bored, sluggish selves wherever we go. We need distractions. We need company. We need intimacy. It is very important to be around upbeat people. We need someone who believes in us. No nay-sayers welcome.
Rating- 7
My husband is the most joyous companion in existence.  My dog also provides good company.  I recognize though that I need additional positive influences in my life since I am alone with my dog most of the time.

*Guest blogger Rachel Fleischman, MSW, LCSW, is a San Francisco-based therapist. Her profile can be found on Psychology Today’s therapy directory.

Well, I officially failed my own self evaluation.  47 out of 100 hardly qualifies as passing.  I guess I have some things to work on!