Reasons for developing depression. External or internal?

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As a psychiatrist we are often asked questions regarding the cause of depression. This probably helps them understand the illness better and patients and their care givers hope that they can avoid the cause and come out of the depression, without the need for medicines.

To be honest, while writing this article, my aim is not only to provide a better understanding of the illness, by explaining its mechanism, but also create an awareness regarding the biological nature of the illness. It’s easier for patients to accepts any other biological illness such as diabetes, hypertension etc., but it’s very difficult to accept depression as a result of changes in brain function.

Categorization of depression

Depression was earlier categorized into two main classes: Exogenous depression and endogenous depression.

As the name suggests,

Exo-genos = external causes for depression
Endo-genos = internal causes for depression

Earlier it was believed that depression can either happen due to unsuitable external factors or due to a reduction of certain brain chemicals (known as Neurotransmitters) but not both simultaneously.

Exogenous depression happens when unfavorable external situations arise, such as a financial crisis, social issues etc. A lot of people during the COVID crisis have undergone massive personal and financial issues. This has caused a lot of people to go into a state of helplessness and hopelessness which in turn has caused depression in few.

Endogenous depression, refers to the presence of depression in the absence of any such unfavorable situations. Typically, it refers to a state, where one fine day a person wakes up and is depressed. There is nothing that has changed around him and yet everything is different.

Logic dictates that in the first case, the treatment should be correcting the cause that leads to a depressive state to begin with. While in the other scenario, since there is nothing to correct or change, medical treatment should be given.

External or internal?

💡The truth is far away from this. The fact of depression is that it seldom is entirely exogenous or endogenous.

In most people, external events can set off a chain reaction which will in turn trigger a series of internal events (changes in the brain) that will cause depression.

These complex changes when caused due to an external cause can be considered to exogenous depression and when they happen in absence of any external factors, they can be considered akin to endogenous depression.

The diagnosis of depression is not made merely on the presence or absence of symptoms, it’s made primarily on the basis of the impact these symptoms have on routine life.

What this means is that even if a person were to have some depression symptoms, but is able to function normally in daily life, they there would be minimal value to treatment. 

For e.g., a person feels sad sometimes, feels disinterested in doing things of his liking sometimes, but is still able to behave normally with his family, is able to do job properly, there is no reduction in his efficiency, then probably there is very little need for treatment.

But for e.g., the same individual is staying aloof, remains quiet, doesn’t interact or participate with family members, doesn’t go out for social gatherings, is not able to focus on work, forgets things, makes multiple mistakes, then it’s important for this person to seem immediate help and start treatment.

Thus, to sum it up

  1. Usually, a combination of external factors and internal factors are responsible for causing clinical depression
  2. Depression is diagnosed in a systematic manner, using structured and validated methods
  3. Once diagnosed, a combination of medicines and psychotherapy are the best methods available for treatment.

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