The Theatre of Depression: A Role for Physical Therapy

We must begin to integrate the expansion of chronic dysfunctions and their relationships with the increasing global burdens of disease and disability. Depression as an affective disorder is one of the more sinister chronic disabilities underscoring a global crisis. Depression needs to be reconceptualized in many ways and particular within the physical therapy discipline. The premise for this discourse is that depression and chronic pain have more similarities than differences…

Depression is often diagnosed as an affective disorder with psychological disturbance and behavioral expressions. Those behaviors often lead to the diagnosis. The etiology of depression is rarely considered. Multiple scenarios and reasons delineate the development of depression. One etiology lies in the spectrum of human losses. The range explaining the spectrum of loss is left to your imagination. Oppression is another possible scenario explaining the onset of depression, whereas someone is blocked from freely functioning consistent with their personal being and will. At a societal level, a tangible example of oppression is the physician, medical, and insurance associated judgements, dismissals, and barriers. Further, think about someone who is repeatedly criticized, rejected, or controlled. On a personal level, depression can be the result of reactions and responses directly associated with obstacles blocking personality and functionality. These societal and personal barriers include a diminishing confidence in abilities and self-esteem. The point is that depression is both a neurophysiological disease and psychosocial dysfunction.

Undoubtedly, depression has similar qualifications as pain including shared biological pathways.

Depression can be expressed through somatic symptoms and the chronicity of pain has the consequence of depression.

Psychological or emotional pain may be seen as depression similar to the way physical pain signals something is wrong enough to need an alternate course of action. Emotional pain like physical pain has the choice of avoidance. Our history of investigating fear gives us the understanding of avoidant behaviors as a reason for the development of chronic pain. Avoidant behavior is also a causative factor of depression. Therefore, depression as a defense mechanism within certain contexts, may be an emotional pain that inspires avoidant behavior. The challenges of life can reach a tipping point that overwhelm personal abilities, resources, and reinforcements. This tipping point can lead to a breakdown in personal coping skills reflecting a psychosocial dysfunction. Depression may be a behavioral choice to shut down similar to the way fear plans movements leading to avoidant behavior. The scrutiny here is that any psychological dysfunction is also linked to social or environmental feedback that reinforces the losses, failures, and rejections. This is also true in the case for adverse events related to loss, failure and rejection, which drive someone to shut down as a perceived appropriate motor response. And, the vicious cycle is created.

The lowest common denominator between all possible scenarios is the difficulty with general functions. There is an individualized point for everyone where a threshold of ability is reached. This tipping point reflective of self-efficacy and grit is lower in some individuals. Consider this suggestion from a perspective of energy expenditure and conservation. We only have so much energy to give. Our behavior is an investment to our success and the success of those we love.

Certain life events and circumstances lead to a depletion of energy, which influence intrinsic shut down similar to a biological depression.

Another way to look at this is like an expected behavioral response to frequently receiving a poor return on investment. This of course is related to chronic stressors and failures that exhaust energy expenditures and reserves. Chronic stress is linked to the onset of depression. After a while, an individual may actually be unable to expect anything more of themselves or the situations, particularly if they repeatedly fall short of their expectation. This is a good place for physical therapy to enter as exercise can build and reinforce the threshold. 

These descriptions help explain depression’s low energy, low interest, and negative cognitions. No doubt… physical activity declines with the progression of depression. These suggestions further connect the psychological factors to the social factors within the biopsychosocial model. Additionally, depression medications can be used to treat symptoms like pain medications are used for physical pain. Medications for depression are beneficial to the individual, but neither long term nor group benefits are clearly understood. In fact, their overall efficacy is being called into question as we continue to see statistical increases in depression.

Additionally, we need to be mindful of many individuals with depression that have overlapping physical and biological symptoms, breakdowns, and pain.

All these comorbidities feed off each other in antagonistic and synergistic manners. And, the downward spiral builds momentum. 

Two questions come to mind…. Why is exercise not a routine physician recommendation for depression? Who is considering a multidisciplinary approach to depression as is suggested for chronic pain? Exercise is critical to the treatment of depression, particularly considering treatment of depression to date has a near singular focus on medications that have not moved the needle. Physical therapy’s ability to consider fear when treating pain carries over to addressing depression. Exercise and direct psychological intervention with medications may provide the best results though it is rarely considered. These assertions are more critical now than ever considering the increasing incidence of depression, abysmal healthcare outcomes, and poor reimbursement schedules for mental health. We can employ behavioral modification tactics involving exercise, diet, and environmental enrichments. Recovery from depression requires both a symptom recovery and a functional recovery.

The evidence supporting exercise for depression is available though not abundant. The literature identifies limited benefits. Be assured that benefits do occur with noted improvements in depression symptoms, quality of life, and self-efficacy. Regardless, exercise provides health benefits that influence stabilization of moods, improvement in health and mobility, and improvements in self-esteem. Exercise certainly helps both mild and moderate depression and inflammation. All this reasoning may move PT closer to the tip of the spear.