Disaster and trauma studies often focus on identifying the incidence of PTSD as the sequel to traumatic events.

Early interventions with those affected after a disaster or traumatic event increasingly utilize psycho-education to clarify and normalize common post-traumatic stress reactions and coping strategies.

While mentioned as a possible response, the high incidence of depression after trauma is less delineated and often goes unrecognized by those suffering.

Depression Occurs after Trauma:

• A Rand corporation study reports that nearly 20 percent of military service members who have returned from Iraq and Afghanistan – 300,000 in all – report symptoms of Post-Traumatic Stress Disorder or major depression.
• In the first long-term study of the health impacts of the World Trade Center (WTC) collapse on September 11, 2001, findings indicate that seven percent of police officers were diagnosed with depression, nine percent with PTSD and eight percent with panic disorder. Twenty eight percent of other rescue and recovery workers had symptoms of depression.
• A survey of survivors from the Oklahoma City bombing showed that 23% had depression after the bombing.
• Depression affects approximately 15 percent to 25 percent of cancer patients.
• After a myocardial infarction, the incidence of major depression is from 15 percent to 20 percent, and an additional 27 percent of patients develop minor depression.

Both major depression and Post-Traumatic Stress Disorder (PTSD) occur frequently following traumatic exposure, both as separate disorders and concurrently.

Depression is the most common disorder suffered in conjunction with Post-Traumatic Stress Disorder.

Depression is nearly three to five times more likely in those with PTSD than those without PTSD.

Overlap of PTSD and Depression

• One possible reason for the tendency to speak more about PTSD than depression is that the overlap of symptoms has made many wonder if they actually reflect the same trauma vulnerability and response.
• While there are different views, most acknowledge them as separate disorders, but register that depression and PTSD do increase susceptibility of the other.
• Persistence of PTSD symptoms is a risk factor for depression; and the presence of comorbid depression seems to predict chronicity of PTSD.
• A recent study by Nixon and Nearmy underscored the importance of differential diagnosis and treatment of depression in the aftermath of trauma to avoid the dropout rate from PTSD treatments not suited to those suffering from depression.

Why Depression after Trauma?

From a psychological perspective, depression is understandable after trauma. Not all loss is traumatic- but all trauma involves loss.

In the face of unthinkable terrorist attack, natural disaster, loss of a child, war, heart attack or life threatening illness, we face loss on many levels. We lose people, resources, connection, safety and the world as we knew it. We come face to face with death and grieve for our lost sense of control and of life.

The Unfolding of Depression After Trauma

While the course of depression after trauma is complicated and varied, some studies find that depression, much like PTSD peaks in the acute aftermath of traumatic events and abates after about four months.

Some have found that that whereas PTSD reduces in long-term follow-up, there is an increase in depression as time goes on. This is often consistent with facing a different reality and an awareness of loss of actual and interpersonal resources.

Symptoms of Depression after Trauma

A diagnosis of depression is usually characterized by five or more of the following symptoms including either a persistent sad mood or loss of interest in life’s pleasures manifested for a two-week period. Any persistence of these symptoms that causes marked functional impairment or suicidal thinking, however, is cause for concern:

• A persistent sad mood
• Loss of interest or pleasure in activities that were once enjoyed
• Significant change in appetite or body weight
• Difficulty sleeping or oversleeping
• Physical slowing or agitation
• Loss of energy
• Feelings of worthlessness or inappropriate guilt
• Difficulty thinking or concentrating
• Recurrent thoughts of death or suicide

It is worth noting that while these are the established symptoms for depression, we have found that men often suffer from depression well hidden behind anger, irritability, medical symptoms and alcohol. It does not mean they are suffering less; it just makes depression more dangerous for them.

Depression after trauma is often heightened by the hyper-arousal that makes concentration and sleep difficult and adds to feelings of depletion.

Persistent pain from injury or medical treatment, intrusive thoughts of traumatic events or grief in the face of unanticipated traumatic loss can often invite a fear of things never getting better, of no hope for the future.

Self-blame and shame about not “pulling it together,” overt sadness, fear of being pitied or of losing respect often keep people isolated with depression and unable to reach for the help they need.

Responding to Depression after Trauma

Depression is nothing you chose.

Depression is not your fault.

Depression does not equate to doing something wrong or failing to do something right.

Depression is about suffering.

Depression can be treated.

• In my experience with people who have suffered with depression, I have observed that if symptoms persist, there is no reason to wait. There is considerable benefit in seeking professional help.
• There is proven value in many individual and group therapy treatments for depression.
• Given the research findings of neurochemical changes implicated in the symptoms of depression, evaluation for medication may be warranted and helpful.
• The combination of therapy and medication is extremely valuable for many.

Self-care and Re-investment in Life

Self-Care and re-investment are difficult, but crucial in the recovery from depression. Consider three antidotes of despair observed by international humanitarian workers in people who have lost all they love to unthinkable circumstances:

Work

The sense of value one gets from work is basic to a sense of mastery, value and worth. If you are able to do some aspect of your work – do it. It will help you remember who you still are.

Given the fatigue associated with depression, don’t try to move mountains if you can’t. Start with small steps like maintaining daily routines. You are coping as best you can. Plan and complete an achievable goal each day be it making your bed, guaranteeing yourself the things you like to eat or meeting a neighbor to walk the dogs. It doesn’t matter what step you are on – it matters you are on the road.

Connection

Don’t go it alone. Connection with others buffers loneliness and reduces the isolation that can increase the rumination and negative perspective of depression. But…who wants to go anywhere when they are depressed?

The dilemma is a real one but the pay off of going anywhere – the family gathering, the lunch with a friend, the therapy group, the book club – is enormous. I urge people to go like it is a job, to go to practice, to go for someone else, to go with a pet, a friend, a tray of cookies, to go because people heal in community.

It is always a surprise to someone who has dragged themselves to a bereavement group to find that everyone has had those moments when they are crying as they drive but still going forward…

Altruism

Being needed is a gift in face of the depression. In a way that is often unexpectedly challenging, physically demanding and emotionally uplifting, a plan to help and give to others is often transformative.

Many have been able to move from the frozen moment of trauma to a better place by working for others in the name of someone they loved. It offers a reason to work, connection, a reason to live, and way to deal with traumatic loss.

Consider work you might do to help another person. One young widow began sewing baby clothes for a mother’s center; a man who lost his son in Iraq began a basketball league for boys; a cancer survivor spent one day a week visiting with others receiving chemotherapy.

We can’t wait for depression to lift before we start moving; but often with small steps of work, connection and altruism, we arrive at a place free of it.

“ We cannot do great things on this earth, only small things with great love.”

Mother Theresa

Traumatic experience photo available from Shutterstock

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    Last reviewed: 10 Aug 2012