Depression and the Three-Legged Stool

Not all depressions are the same and getting it right matters.

Broadly speaking, depression can be divided into two types, exogenous and endogenous. This is not to say that any particular depression is necessarily one or the other. There can be factors of both at play and to different degrees.

Exogenous as it relates to depression implies there was a known trigger or event that precipitated the depression. Some known triggers include job loss, separation, loss of a family member, interpersonal conflict, trauma. Here the depressive symptoms can be easily attributed to those events. The depression makes sense in the context of the person’s actual experience.

In cases of endogenous depression, there are no known triggers or precipitating events. The similar feelings of being overwhelmed, dread, emptiness or pervasive sadness invade and the person may be at a loss to understand why. In some of these cases, when feelings of depression develop, the person may look for factors external to themselves to account for the depressive feelings. In so doing, more minor events may be elevated in status in an effort to account for the tremendous feelings. However with a more objective view, it can be determined that those events really can’t account for the degree of depression.

Of course, there can be serious life events and you can also have or will endure a depression that is also independent of those life events. This can be thought of as a double whammy.

Whether endogenous or exogenous, both types of depression may be treatable with the use of antidepressant medication. Whether or not medication may be indicated depends on the length and severity of the depression.

Notwithstanding medication, counseling remains a potent treatment option. Here is where one’s understanding as to the cause of the depression factors in. For counseling to be most effective it best match the factors that gave rise to the depression.

For exogenous depression, one needs to understand and appreciate the trigger or precipitating event. If one has been subject to a particular trauma, then the counseling of choice would be trauma counseling. If the depression relates to one’s relationship, then some form of interpersonal counseling would be indicated. If the depression is related to the loss of a friend or loved one, then bereavement counseling would be indicated.

If however it is more determined that the depression is endogenous, that there is something about the person’s biology that predisposes them to depression absent any particular trigger, then cognitive-behavioral counseling would be indicated.

In cognitive-behavioral counseling the person learns strategies to influence the symptoms of depression by helping them manage how they interpret what is happening with regard to their feeling states and learning behavioral strategies to in a sense either work with or work against the depressive symptoms. With cognitive behavioral-counseling, it is as if you want to find a way to own the symptoms and manage them rather than the symptoms owing you and managing you.

Having an endogenous depression doesn’t mean you are exempt from other serious and troubling life events. Depression can be both endogenously and exogenously determined. In the situation where both factors may be at play, then a combination of counseling approaches may be indicated with one at least being cognitive-behavioral.

All this matters because applying the wrong type of counseling can create the impression that something may be the source of the problem when it is not. This can lead to treatment failure and perpetuate and even intensify the depression. It can also cause problems where none existed before such as in the case of creating interpersonal problems when the suspected interpersonal behavior may not have been as significant as first led to believe.

Before running headlong into treatment, it is important to have a good understanding as to the nature of one’s depression. If you run into treatment, you will get the treatment your treatment provider has been trained to deliver, but you won’t necessarily know if it truly matches your needs.

Assessment for depression relies on a bio-psycho-social approach. Think of this as a three cornered stool. Assessing only one or two parts leaves the situation unstable. The stool with only one or two legs topples. All three aspects must be explored.

The assessor must ask a multitude of questions regarding one’s past and present. This should include questions about one’s family extending to at least the parents and if possible, the grandparents. The inquiry should look at family dynamics, history of mental health problems, interpersonal conflicts and behavior and even broader social factors such as place of birth and access to resources. Of concern is also a history of substance or alcohol abuse, family violence and mental illness. The person’s prenatal, birth and developmental history should be explored as well as academic performance. The assessor must also explore for current or recent or longer ago life experiences that may have been untoward or distressing in nature. Medical issues need also be determined. One’s health and diagnosed or yet to be diagnosed medical conditions may also play a role in depression.

In other words, the assessment of depression is multifaceted.

The above areas of exploration are not exhaustive of all the areas to be explored. To add, depending on what is discovered in any particular area may lead to further and deeper exploration to best understand the contribution of that factor. If someone runs to treatment in the absence of first trying to understand what gave rise to the depression, the treatment may not be of value or worse, can make matters worse.

If you are depressed or suffer depression seek a mental health professional who will take a bio-psycho-social perspective to assessing your depression. If necessary, that mental health professional can work with other service providers if more help is necessary to explore any of those particular issues. In the end, we want you to get the right help and the best help available. Admittedly some of this is as much art as science. Some depressions are more challenging to assess and treat. However, starting off right can lead to better outcomes.

We start by trying to figure out if the depression is endogenous or exogenous. If endogenous, then we want to know if there are any diagnosed or undiagnosed medical conditions contributing to the depression and if so, apply the appropriate medical treatment as necessary and as indicated.

If the depression is thought to be exogenous, then we want to understand the contributing factors there and apply the appropriate course of counseling. Sometimes the treatment will include a multiple of approaches, particularly when there is thought to be a multi-causality of factors underlying the depression.

Remember the bio-psycho-social approach to assessment. Remember the three legged stool. The three legged stool makes for the most stable platform. So too does the bio-psycho-social assessment.

I am Gary Direnfeld and I am a social worker. Check out my services and then call me if you need help with a personal issue, mental health concern, child behavior or relationship issue. I am available in person and by Skype.