Primary Vs. Secondary (aka Reactionary) Depression
Primary Depression
Fixated on irrationally negative thoughts in reaction to mostly normal situations
Difficulty seeing any situation in a positive light
Lack of interest in participating in activities once enjoyed
Inability to get joy out of life's simple pleasures
Secondary Depression
Fixated on rational negative thoughts in reaction to traumatic situations
Difficulty seeing the objectively negative situations in a positive light
Inability to participate in previous activities causing distress
Inability to appreciate the joy from life's simple pleasures
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Both
Suicidal and self-harming thoughts
Lack of motivation/desire to give up
Frequent negative thoughts
Lack of dopamine and serotonin
Negatively impacts the quality of life
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Primary Depression
"I'm going to be alone forever"
"I failed my exam which proves I am worthless and will never succeed."
"My friend canceled our plans, she must secretly hate me because I am so pathetic."
Secondary Depression
"My mother is dead and never coming back"
"I have to live with this chronic pain for the rest of my life"
"I can't work anymore and am totally reliant on my family. I am such a burden."
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Summary
As you can see, the first set of thoughts is irrational and someone should try not to think those things about themselves. Accepting those thoughts as facts would be a bad outcome. However, the thoughts in the secondary depression column, despite being just as depressing, contain unchangeable rational facts. Therefore while someone having the first thoughts should try to replace their thoughts with more positive ones, someone with the second set of thoughts might need to learn to accept these facts and simply move on to trying to live the best life they can have despite them. Even if they are phrased very negatively (for example I don't believe people with disabilities should feel they are a burden) there are still underlying truths that must be accepted.
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In my last post, I addressed ACT as the ideal therapy for people with chronic illness. In this post, I discuss the technical term for what much of the depression in the chronic illness community is aka secondary depression or reactionary depression and how you can tell the difference and get the treatment right for your mental health.
Secondary or reactionary depression is when someone gets depressed in reaction to a serious negative or traumatic event. The most common example of this is grief following the death of a loved one. It is also extremely common following chronic or terminal illness diagnoses.
It is important for clinicians to look out for and differentiate primary and secondary depression as they can benefit from slightly different treatments.
In primary depression, treatment revolves around learning to recognize irrational (negative/disempowered) thoughts and replace them with more rational (positive/empowered) thoughts. For example, instead of thinking "I am going to be alone forever" thinking "How can I meet new people?" Therapies like CBT (Cognitive Behavioral Therapy) can help people to recognize irrational thoughts and correct them until they begin to do so automatically.
However, since primary depression also involves a large physiological response in which the brain is unable to produce dopamine and serotonin in response to usually positive experiences, people with primary depression will often struggle to improve without addressing this physiological imbalance through the use of SSRI or SNRI antidepressant medication. This medication works with therapy to produce the best possible results. Other experimental treatments also focus on the physiological changes in primary depression-like inflammation and changes in white matter in the brain.
In contrast, people with secondary depression often do not have irrational thoughts. They are just fixating on rational negative reactions to their situation. Therefore, there might not be a good way to reframe their thoughts as positive.
However, in the case where it is simply not possible to increase small positive experiences in a person's life, or where they greatly struggle with therapy and acceptance, medication can help to amplify the effect of life's small pleasures, thereby hastening recovery and minimizing suffering. In addition, some medications like SNRIs can address chronic pain which may improve the patient's mood indirectly through decreasing their negative experience (aka pain).
In conclusion, it is essential to differentiate between primary and secondary depression both to avoid gaslighting and to more effectively treat both conditions. Primary depression involves physiological changes to the brain that makes treatment significantly more challenging. Whereas secondary depression suffers from the painful reality that it is often a rational response to a difficult situation.
For instance, thoughts like "my mother is dead and never coming back" or "I will have this chronic pain for the rest of my life" may just be true facts about this person's life. Therefore, treatments like CBT that try to frame the person's thoughts as irrational can end up gaslighting the patient, rather than helping. Instead, the best therapy to treat secondary depression is ACT or Acceptance Commitment Therapy. This therapy focuses on accepting things you cannot change and learning to live a good life despite this negative change in circumstance.
Additionally, unlike in primary depression, much of the deficit in dopamine and serotonin in secondary depression is not due to the inability to produce these chemicals but rather a lack of circumstances in which they can be produced. For example, people with newly developed chronic illnesses often lack the ability to participate in the activities that once brought them joy. Therefore, instead of immediately turning to medication, an effort should be made to increase the person's focus on small positive experiences like eating food and seeing a pretty view. As time passes the person is likely to begin to reframe what constitutes a happy experience in their life. This effect is known as the happiness treadmill. Thus secondary depression treated with ACT may be self-limiting and not require medication.
