While I don’t appreciate the nasty tone of many comments on my post about J.K. Rowling’s Suicidal Days, they have caused me to rethink my claim that divorce doesn’t CAUSE depression—even if it can TRIGGER it.
Big whoop, you say: the semantics of those two words: “cause” versus “trigger.” But I realize that in distinguishing between those two terms, with no further explanation, that I wasn’t communicating clearly my theory—backed by the Hopkins doctors I work with–of how stress affects depression. This is a delicate subject that I’ve spent a fair amount of time thinking about and researching.

So when Holly sent me the link to Mr. Dooce’s blog post (click here to get to) on why he, as a spouse of a depressive under tons of stress, has started Prozac, I read with interest his claims and explanations to readers, all of which I agree with.
His readers’ questions fall into two categories. The first: “So you have stress. Big deal. Everybody has stress. You are saying that stress lead to depression? Give me a break.”
Mr. Dooce responds by mentioning a few sites and pages he likes that are great resources like the MayoClinic.com, and then he quotes from an online article called “Do You Love Someone Who Suffers From Depression?” by Dave Turo-Shields:

Sometimes the spouse of a depressed partner becomes depressed as a result of living within a “depressed lifestyle” for too long. Depression is said to be contagious and can become a shroud over the spouse or family. It’s also vital to consider that depression may not only be genetic, but it can also be taught. You heard me right. For instance, our children’s most powerful classroom is the home. Both “Nature and Nurture” contribute to depression.

The second category of questions: “How do you get from stresses of living to depression?”
Mr. Dooce replies:

As I said above, it is in my response to situations. The other thing that I think is going on is that the continued level of stress is high and I’ve been unable to fully relax and de-stress. There is interesting research around stress and serotonin.

He then cites another informative article, “The Neurobiology of Depression,” by Juan F. Lopez, M.D., and he quotes passages of the section called “Stress and Serotonin”:

We are not saying that stress “causes” depression in people. Rather, stress is very likely interacting with an inborn genetic predisposition, such that, in some vulnerable individuals, a stressor can precipitate a mood disorder (i.e., vulnerability + stress = depression). Studies in twins have shown a clear interaction between genetic predisposition and a recent stressful life event in the precipitation of a depressive episode.26 There are even cases in which the genetic predisposition is so high that an episode of depression can occur in the absence of any apparent precipitating factors.
The study of chronic unpredictable stress in animals has given us important clues about depression. In our research, we expose rats to different, mild to moderate stressors every day, therefore making the stress “unpredictable” from day to day. Rats that undergo this treatment show LHPA overactivity and increases in peripheral glucocorticoids, very similar to those found in depression.9 Other changes in brain chemicals occur which we have also found in suicide victims with a history of depression.32 This suggests that a chronic or severe stress (e.g., loss of a spouse, serious illness or injury, history of abuse) may cause similar neurochemical changes in vulnerable people, therefore triggering episodes of depression.

Mr. Dooce’s conclusion:

Which leads to my final response around the question that stress is causing a physical manifestation of illness, i.e., “mystery illnesses”. I believe this is the case. I believe that I’ve had this happen in the past, where I’ve been down for more than a few days and it always is due to major stresses and changes in my life. It has gotten much worse as I’ve gotten older and the stakes have gotten higher. I believe that in the summer of 2006, the lawsuit and the cost for us financially caused my two week mystery illness.
I’m doing this to help myself.

I feel badly if I communicated to readers that I didn’t think J.K. Rowling suffered from “real depression” because hers was triggered by divorce, and helped by some therapy and caring for her daughter. My irritation didn’t lie with Ms. Rowling, but in the media’s interpretation of her depression.
Too often, when any of the celebrities suffers from a mood disorder, we get this over-simplified cause and effect equation that just isn’t the case with many of us who suffer from chronic depression. And so stories like that tend to strengthen the unfair “buck up, wimp!” solution that our siblings and co-workers, and parents say to us.
“Hey, J.K. Rowling got out of her funk with a few therapy sessions and looking to her daughter. So why can’t you? Why after ten years, are you still in this negative vortex? You must not be doing something right.”
That was my frustration more than Ms. Rowling’s description of her depression. I hope I have made this absolutely clear on Beyond Blue: I have sincere empathy for any person who suffers in any way from depression and/or anxiety—from those who suffer fleeting moments of anxiety as they board a plane to the ones who have been hospitalized more times than they have fingers and toes. If I didn’t convey that in my Rowling post, then I apologize.
As far as the relationship between stress and depression: if stress can cause a “real” depression, I went back and reviewed Chapter 5 of “Understanding Depression” by J. Raymond DePaulo Jr., M.D. He writes:

Most people who suffer from severe depression are not depressed all the time. They have long periods when they are free from illness for years. Then something happens and they have a relapse, but what is that something? It is natural to look for a precipitating event or the stressful situation that is culpable and it is just as natural to find the stress or trigger. But this exercise begs the question: What exactly is the relationship between stress and depressive illness?
There are two ways of looking at the question. One is to look at the timing of the event and the onset of the depressive or manic condition. If you get hit by a piano that’s fallen out of a tenth-floor apartment and are instantly killed, then we can rightly say you died from the event. But if you got up and walked away apparently uninjured and died twenty months later while walking home in the hot Florida sun, it would be reasonable to look for some other cause. The piano that struck you might have contributed to your sudden death in ways that we could imagine (maybe a heart injury or a chronic subdural hematoma that left you vulnerable to overexertion), but it would require considerable detective work to prove it. The closer the event and the outcome are to each other in time, the easier it is to see a cause and effect relationship between the two. When it comes to depression, however, this natural way of looking at things creates more confusion than almost anything else for patients, families, and their health professionals.

“Depression is when your dog dies and you feel sad.” That was how one of my patients sarcastically put it. Well, he’s wrong, but he’s also right! When you lose a loved one, whether it’s a close family member, a good friend, or a pet, it’s natural to grieve. But some people, probably because of their genetic makeup, can become clinically depressed when they lose a loved one. On the other hand, I have also seen more than twenty patients who became manic after a grievous loss. What we are talking about here are precipitating factors. I use the word “precipitate” to refer to factors that seem to determine when someone will get depressed or manic, as opposed to factors that determine whom is most likely to have depressions or manias in their lifetime. Precipitating or “stressful” life events can lead to depression in some people and discouragement in others. One is an illness, the other is a natural response to misfortune.