Why Depression Is Often Just the Tip of the Iceberg

Depression is highly individual. Understanding the unique biological, psychological, and social factors at play is critical to precisely diagnosing and treating depression in each patient.

Consider two people who were diagnosed with depression. Although each person has the same diagnosis, they have their own personal narrative and clinical history. For example:

• A 20-year-old college student after a breakup with his girlfriend.
• A 36-year-old professional after quitting her job.

What if we learned that the 20-year-old college student had a childhood history of separation anxiety with an abusive and (at times) neglectful family? In his relationship, he became fearful of intimacy and became unfaithful to his girlfriend, leading to the breakup. In another iteration of the patient’s narrative, he started to emotionally and physically disconnect from his social relationships, stopped going to school and work, and consumed marijuana in high amounts.

What if we learned that the 36-year-old professional was underperforming at work due to an inability to manage all her tasks and responsibilities that bring her to feel “overwhelmed,” along with mood swings that have interfered with work relationships? In another iteration, she lost her mother a year ago to cancer and dove into her work immediately after that loss. In yet another iteration, she recently returned from maternity leave and began experiencing sleeplessness and an alternation between jubilance and energy, and depression.

In each of these narratives and clinical histories are the underlying and contributing factors to their depression.

In the first iteration of the 20-year-old student, he may be experiencing post-traumatic stress disorder because of his childhood history of abuse and neglect. To “conquer” his separation fears he self-sabotages and pushes his partner away. This then creates intense loneliness and later depression. He could benefit from an antidepressant medication and psychotherapy targeting emotional attachment issues.

In the second iteration of the 20-year-old student, he is likely showing early signs of psychotic illness. This person requires more immediate psychiatric evaluation and care. He could benefit from an antipsychotic medication or mood stabilizer. Treatment would include family interventional support and psychoeducation.

In the first iteration of the 36-year-old professional, she may have an executive functioning disorder, most typically attention deficit hyperactivity disorder (ADHD). She may have difficulty completing tasks or switching to new tasks. Starting her on a stimulant medication and a serotonin-selective reuptake inhibitor (SSRI) may have beneficial effects. She would also likely benefit from psychotherapy to target emotion regulation and an executive functioning coach to help her navigate multi-stepped processes and time management.

In the second iteration of the 36-year-old professional, she may have complex grief (and possibly post-traumatic stress disorder) because of her loss. She may benefit from an SSRI medication, bereavement counseling, and/or emotional attachment-focused psychotherapy.

In the third iteration of the 36-year-old professional, she may be experiencing a postpartum mood disorder, an early sign of bipolar disorder. She could benefit from mood-stabilizing medication and family interventional support and psychoeducation.

Each person has a story to tell and a reason for their depression. That's not only important from a human perspective, but essential for a diagnostic and treatment approach.

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