At 3:00 a.m., millions of emotional alarm clocks go off all over the world, waking people in a panic:

"What's the point? Do I really matter to anyone? Do I have a place in other people's lives? Who knows me? Who cares? Why do I feel so unimportant?"

And even worse:

"I despise myself. I am truly worthless. I have been a burden to everyone. I hurt people. I don't deserve to live."

Some get back to sleep after an hour or two of tossing and turning. Others start their day at this early hour filled with dread. Showering, dressing, preparing breakfast (if they're able to eat at all) take monumental effort. "Keep going" they tell themselves, trying to complete simple activities that most never think twice about. Finally, in an act of incredible courage, they push themselves out the door and start off to work, struggling against emotional headwinds that make every step an exercise of will.

The prevalence of depression in the United States is alarming. According to Nemeroff (1998) (from The Neurobiology of Depression ), "5 to 12 percent of men and 10 to 20 percent of women in the U.S. will suffer from a major depressive episode at some time in their life (and) roughly half of these individuals will become depressed more than once." And these statistics do no include incidences of the less severe but lingering depression known as dysthymia.

What causes depression? Is it a biological disorder caused by neurotransmitter or hormonal imbalances? The logical consequence of faulty or pessimistic thinking? Or the inevitable outcome of childhood trauma? A whole book could be devoted to this topic, and the answer would still not be clear. The problem is that the three explanations are interrelated, and, perhaps none, alone, are completely adequate. Consider the following:

• Nemeroff reports that early emotional trauma has important and lasting neurobiological effects (at least in other species).
• Perceived inability to manage current threats affects neurotransmitter functioning (see Albert Bandura's (1995) book: Self Efficacy: The Exercise of Control [W.H. Freeman, New York]).
• Pessimistic thinking although "faulty" when applied to current situations, may not have been "faulty" during childhood, within the context of a dysfunctional family.
• Studies of identical twins separated at birth suggest that genetics play a role in depression, but don't tell the whole story.
• One child from a dysfunctional family may experience severe depression, while another remains untouched.

If this seems challenging or confusing, it is. In the depression flow chart, the arrows point in almost all directions.

Still the suffering remains. While I have no answer to the big question of causality (although I suspect all three "explanations" play a role in many depressions), there is one observation that I would like to pass along from my years of treating depression. That is: many chronically depressed clients I have worked with have had a childhood marked by the absence of voice, or what I call "voicelessness."

What is "voice?" It is the sense of agency that makes us confident that we will be heard, and that we will impact our environment. Exceptional parents grant a child a voice equal to theirs the day that child is born. And they respect that voice as much as they respect their own. How does a parent provide this gift? By following three "rules":

1. Assume that what your child has to say about the world is just as important as what you have to say.
2. Assume that you can learn as much from them as they can from you.
3. Enter their world through play, activities, discussions: don't require them to enter yours in order to make contact."

(See "Giving Your Child Voice" for more. You may want to consider your own personal history to see whether your parents followed these "rules".)

What happens when a child's feelings, thoughts, wishes, and interests are never heard? He or she feels worthless, non-existent, and incapable of having an effect on the world. A child without voice has no license to live. These feelings don't go away as a child get older, instead they go underground, replaced by eating disorders, acting out, painful shyness, or sometimes over-responsibility (a child acting like an adult).