Overview

“Depression is a mood disorder that causes a persistent feeling of sadness and loss of interest.” [1]. This condition can affect how one feels, thinks and behaves and has other negative effects on the person’s emotional and physical health. A person’s day to day activities can also be affected depending on the severity of his/her depression. It is normal for anyone to feel sad or low at times, but these feelings usually are temporary and go away with the passing of a little time. In people who are suffering from depression however, these feelings do not go away in a few days rather they persist for much longer periods of time. In patients diagnosed with depression, there is an overemphasis on negative emotions and events and the state of anhedonia (difficulty in experiencing pleasure). According to [2], for someone to be clinically diagnosed with depression, these symptoms must be present (most of the day), nearly every day for at least two weeks.

Causes/Contributing factors

Research suggests that a combination of genetic, biological, environmental, and psychological factors can play a role in depression. There is also evidence that certain type of serious illnesses or medication taken to combat such illnesses can cause depression like symptoms. Difficult circumstances in life such as losing a loved one, going through divorce naturally causes feelings of sadness within a person but those feelings can persist in some cases leading to depression if left unchecked. Family members and friends should be aware of this so it can be detected if symptoms persist. We can see that a complicated condition like depression does not have a single cause but can be triggered by a range of factors which can be different for each person and his unique situation. For example, a person might go through a divorce and this can trigger sadness and as a result can make him prone to certain other behaviors or actions. In such a situation that person is arguably more likely to indulge in those negative or sinful behaviors which in turn play on the person mind and causes a sense of guilt which could exacerbate the overall situation. The impact certain events have will not be the same for each person, there are always specifics that can show us the impact a certain “loss” might have. For example, let’s say that person A and person B lose their jobs. The impact this event has on those individuals could be determined by several factors. Some determining factors include – how much pride is associated with holding a job, perceived loss of respect, family history of depression, family history of financial stability or instability (which may have resulted in problems in the past) and one’s own financial stability when he/she lost the job. In summary, in addition to a person’s family history, there are several stressful events such as job loss, heavy financial losses, loss of loved one, giving birth etc. that can act as triggers for behaviors associated with depression which when left unchecked can result in depression as a result of failure to cope.

Brain areas implicated

According to [4], the key areas that are impacted by depression are prefrontal cortex, amygdala, nucleus accumbens, and hippocampus. Depression is associated with a downward spiral of emotions that can be a result of stress and failure to cope with it.

            Figure 1 – [4]

Amygdala – The amygdala is an almond-shaped set of neurons located deep in the brain’s medial temporal lobe. It is known to play a key role in the processing of emotions. [5]

            Figure 2 – [5]

Hippocampus – This is a small, curved formation in the brain that plays an important role in the limbic system. It is involved in the formation of new memories and is also associated with learning and emotions. [6]

            Figure 3 – [6]

Prefrontal cortexThis is a region associated with planning complex cognitive behaviors such as executive function and expression of appropriate social behavior. [7]

            Figure 4 – [7]

Hypothalamus – This is an important area in the center of the brain which plays a critical role in hormone production and helps to stimulate other important processes in the body. It is located between the pituitary gland and thalamus.

            Figure 5 – [8]

Pituitary gland ­– This gland is a master gland in the body as it controls several other hormone glands in the body. This gland secretes hormones from both the front and back part of the gland. It is situated in a bony hollow, just behind the bridge of our nose. It is attached to the base of the brain by a thin stalk. [9]

            Figure 6 – [9]

Nucleus accumbens – The nucleus accumbens (NAc or NAcc), also known as accumbens nucleus is a region in the basal forebrain rostral to the preoptic area of the hypothalamus. The most widely recognized function of the NAc is its role in the reward circuit of the brain. Whenever we do anything pleasurable the NAcs are activated resulting in the increase in the dopamine levels in the nucleus accumbens.

            Figure 7 – [10], nucleus accumbens represented by a red dot.

The stress response occurs within the HPA axis (involving the hypothalamus, pituitary gland, and adrenal cortex as shown in figure 1). The stress response is triggered by the amygdala which is particularly associated with the processing of negative emotions. When someone experiences negative emotions, the amygdala becomes more active which triggers the stress response in the HPA axis. This releases glucocorticoids which then trigger a positive feedback loop with the amygdala and negative feedback loops with the hippocampus and prefrontal cortex (figure 1). When the balance of excitation from the amygdala and inhibition from the hippocampus and prefrontal cortex favors HPA activation (i.e. amygdala excitation > hippocampus & prefrontal cortex inhibition), positive feedback occurs which can result in chronic stress and depression. Chronic stress is also known to produce excess levels of glucocorticoids which can lead to the death of neurons, especially in the hippocampus area.

Studies have shown that the amygdala is particularly active when we experience negative emotions. In depressed people, their amygdala is extremely active when compared to a normal person’s amygdala activity. Thus, an overactive amygdala could be one contributor to depression. As we discussed previously, it is the ability to cope with stress matters. Whether this stress is controllable or not seems to be decided within the ventromedial prefontal cortex (vmPFC). The vmPFC can affect amygdala activity via a serotonin-releasing intermediary. If the stressor is controllable, the vmPFC ultimately makes the amygdala inactive. On the other hand, if the stressor seems uncontrollable, amygdala activity increases and triggers a stress response which favors amygdala activation and thus increases the negative mood. If this sequence persists for longer periods of time, excessive glucocorticoids can be released which can cause damage both in the hippocampus and in the vnPFC itself. The result of this is a further reduction in the vmPFC activity that leads to further amygdala activation and a negative emotional bias. Thus, overactive amygdala misregulated by the prefrontal cortex, is a key player in the development of depression. An overactive amygdala can create a cognitive bias towards interpreting the world, and self, negatively. This increase in negative thoughts is associated with dysfunction in the brain’s reward system especially in the nucleus accumbens (NAc), in which the rewarding effects of dopamine are lessened.

Symptoms of Diagnosis

A person who may have depression will exhibit one or more of the following symptoms which sometimes require an honest reflection about ourselves. The following are some signs:

  • Apathy – A loss of interest in the activities one used to previously enjoy.
  • Helplessness or hopelessness – When one feels like there is very little that can be done by them or anyone else to improve their life.
  • Changes in habits – Sleeping or eating too much or too little can be a sign of depression. Engaging in risky behavior, excessive drinking can also indicate depression.
  • Chronic fatigue – If one is feeling tired all the time, it could also indicate depression or anxiety or some other underlying medical condition.
  • Difficulty focusing or making decisions – “People who are depressed and anxious have difficulty making decisions because they worry whatever they do will be wrong”, says Dr. Miller.
  • Mood swings – When someone gets easily irritated or if they experience frequent mood swings, it could also indicate depression.
  • State of constant worry – When someone overly focusing of problems and anticipating them, it could be a sign of depression or an anxiety disorder.

A normal person may also experience these feelings but in depressed people these feeling persist and they are unable to cope with them.

Impact on individual life

Depression can have a wide range of effects on an individual’s daily life and the lives of loved ones. These effects can include being disconnected from the happenings around them (being lost), unable to focus on their family obligations or individual obligations (religious or otherwise). Depression affects individual personality, their habits, their ability to socialize, their ability to live a productive and fulfilling life, their ability to remain present in the moment, their ability to show interest in the lives of loved ones. It affects the individual at a deep level.

Relationship with Allah ­– I have seen firsthand how depression affects someone’s relationship with Allah. My beloved mother has been suffering from depression for the greater part of this past decade. When she seems to be having a low (this is when she is angry or easily irritable), I have seen her in salah unable to focus. On other occasions, I can recall seeing my mother unable to remember which raka’ she is in and missing her sujood occasionally. To understand the powerful impact depression has on this area of a Muslim’s life, all I need to do is compare this state to how her relationship with Allah was before she was affected. I can recall how much Qur’an my mother used to read, how regular she was with her dhikr, how much she reminded her children to read the Qur’an. Depression not only affects their “quality” of worship but also can impact the frequency of ‘ibaadat. But only Allah knows how much value this prayer has in His eyes. Getting up and asking Allah to “guide us to the straight path” in this condition shows immense strength and resolve. This should also motivate others to look at our own prayers and look for ways to improve. Allah will judge each person according to the intellect and ability he blessed them with.

Relationship with others – If the most important relationship in a Muslim’s life (relationship with the Creator) is affected, then it should be no surprise that this condition also affects relationship with His creation. Depression floods the person’s mind with negative thoughts and emotions and no matter how much they try, they are unfortunately unable to cope up with it. This can be exhausting and draining and individual’s in this condition can be easily irritated or angered. What triggers these emotions can vary from person to person.

Primary caregivers can experience a lot of stress, both physical and emotional. In many cases, the primary caregivers end up putting their loved one’s needs before theirs and this can take a toll on their own well-being and lead them feel a reduction in quality of life. It is possible for caregivers to develop feelings of sadness, loneliness, guilt and anger. If these feelings persist, it can lead to caregiver depression. Primary caregivers along with close loved ones can also feel guilty and question if they are doing enough for the loved one? Often as human beings, we tend to compare a lot and focus on things that we do not have which makes us forget the things we are blessed with. The spouse of a depressed person might look at his/her friends and compare their live and feel that they are unable to enjoy their life as other couple do because of depression. This can lead to lack of satisfaction in life. Children who have a depressed parent might look at conversations their friends have with their parents and realize that they are unable to have those type of conversations. It is tough, sometimes as loved ones we just want our family member to come back to us as they were before depression. We might even question “’why is this happening to us?”, “why did Allah choose our family member for this?”. It is important to remind ourselves of the blessings we have, stay motivated, seek help when needed so we can help ourselves, our families including the affected family member.

Here are somethings that can be done to avoid caregiver depressions.

  • Reach out for help – depression isn’t something that we can snap out of, on our own.
  • Maintain other relationships – spending time with close friends, relatives can help provide hope and strength.
  • Start a journal – journaling can help improve the mood by allowing one to express their emotions.
  • Stay positive – It is important for caregiver to remain positive and remind themselves that they are making a big difference in the life of the loved one for which they will be rewarded by Allah subhaanahu wa ta’ala.

Treatment

Medications and psychotherapy are known to be the most effective treatment methods for people with depression. Medications can help with alleviating symptoms and psychotherapy is a process when the depressed individual can talk to a mental health professional which can also be very effective. When it comes to medication, it is rather common to try different medications or a combination of medications before one finds the one that works effectively. This can be a tough phase where people might feel that nothing is working. Finding the right medication requires patience. It can also take several weeks or longer for the medication to take full effect and the side effects to ease as the body adjusts to that medication.

It is also risky to stop taking the medication abruptly. We should consult with the doctor before taking any action and get a gradual plan of reducing the dose. Withdrawal symptoms are also experienced if the patient misses several doses of medication. It is very important to take medication consistently and dose should only be reduced slowly with approval from doctor.

Psychotherapy is a mechanism to treat depression where the affected individual talks to a qualified mental health professional. They can completely understand what the patient is experiencing through talk sessions with them and overtime they can work on replacing the negative thoughts and feelings with positive ones.

Psychotherapy can help in several ways including the below:

  • Find thought patterns that are negative and replace them with positive thoughts
  • Regain a sense of satisfaction and control in life
  • Help with adjusting to difficult circumstances and learn to respond in better ways
  • Develop ability to tolerate and accept distress using healthier behaviors

There are also other treatment options like electroconvulsive therapy (ECT) and transcranial magnetic simulation (TMS). In ECT, small electrical currents are passed through the patients brain so that it impacts the function and effects of neurotransmitters in the brain to relieve depression. In TMS, a treatment coil is placed against the scalp which send brief magnetic pulses to stimulate nerve cells in the brain that play a role in mood regulation and depression. Both these methods are use for people who don’t respond to medications/antidepressants. Side effects need to be understood before undertaking such treatments. [10]

Family support system

It is very tough to support and take care of someone with any mental illness. There are so many challenges which can trigger feelings of anger, frustration and helplessness that could leave the family wondering what else to do. If this ailment is so challenging for the family, it can be even more challenging and draining on the individual which is why they need our support, love and gentle care during this time. Here are some thing family members can do to help the situation.

  • Educate themselves on all the symptoms of depression
  • Understand the behaviors of the family member and make a note of it. This can help us build more compassion and patience when certain situations arise.
  • Never criticize the depressed individual by saying things that can be hurtful and trigger even more negative emotions.
  • Always encourage treatment with wisdom and compassion.
  • Avoid doing or saying things that are known to have triggered a negative reaction in the patient or things we know might trigger such a reaction.
  • Encourage them to be physically active. A morning walk, evening walk or any interaction with nature can be very soothing for all.
  • Encourage and ensure the patient is taking his/her medication consistently even though they may dislike doing so. They may even trick us into believing that they have taken the medication. They might hide the medication of throw it away. So, it is important to ensure they are taking it.
  • Encourage participation in spiritual practices
  • Always provide positive reinforcement and encouragement. Never even discourage, name call or call out certain behaviors. Remember they are not in control of their emotions, but we are.
  • Create a low stress environment in the house by setting a very practical and easily achievable routine.

No matter how challenging it gets, people with depression deserve the family’s love, patience, encouragement, support especially from the primary caregiver. Other family members should also keep an eye out for the primary caregiver and support him/her while being always aware that their job is very stressful and can sometimes lead to caregiver depression.

Jabir radiallahu anhu reported: The messenger of Allah ﷺ said, “Every disease has a cure. If a cure is applied to the disease, then it is relieved by the permission of Allah Almighty.  In another hadith, reported by Abu’l darda’ radiallahu anhu who said: “The messenger of Allah ﷺ said: ‘Allah has sent down the disease and the cure, and has made for every disease the cure. So, treat sickness, but do not use anything haram.’” (reported by Abu Dawood). Trials and tribulation are part of life. No matter how much we dislike them, we will face them. This is the reality of this world and this is what our Prophet ﷺ taught us. Prophet Muhammad ﷺ faced so many challenges and calamities in life and he was the most beloved to Allah and the best of creation. One needs to remember that

trials and tribulation do not always mean that Allah is upset with a person or that he is punishing us for our actions. One must look at our actions, and if they are in accordance with the rules set by Allah, then one can be at peace that those trials are not a means of punishment but a means of elevation.

Allah has informed us that he will test us, but he also informed us that he will not burden a soul more than what it can bear. Allah has a plan and there is always wisdom in His plan which we fail to see many times. So never lose hope, help is always near, cure is always near in sha Allah.

May Allah grant shifa to all those who are suffering. He alone can cure.

References

  1. https://www.mayoclinic.org/diseases-conditions/depression/symptoms-causes/syc-20356007
  2. https://www.nimh.nih.gov/health/publications/depression/index.shtml
  3. https://adaa.org/understanding-anxiety/depression
  4. https://qbi.uq.edu.au/brain/brain-diseases/depression/depression-and-brain
  5. https://www.sciencedaily.com/terms/amygdala.htm
  6. https://www.verywellmind.com/what-is-the-hippocampus-2795231
  7. https://www.sciencedirect.com/topics/neuroscience/prefrontal-cortex
  8. https://www.medicalnewstoday.com/articles/312628.php
  9. https://www.pituitary.org.uk/information/what-is-the-pituitary-gland/
  10. https://www.mayoclinic.org/diseases-conditions/depression/diagnosis-treatment/drc-20356013