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Depressive illnesses affect the lives of millions of Americans and cost billions of dollars. In the United States, nearly 10 million people experience a depressive illness during any 6-month period. They and their loved ones pay an enormous emotional price. Depressive illnesses cause grief and pain, contribute to family disruption, interfere with depressed people’s ability to function, and, at times, lead to their premature death. While no price tag can be applied to such human suffering, the economic costs have been estimated at $16 billion annually of which $10 billion is due to time lost from work.
The good news is that depressive illnesses are among the most treatable of all the mental illnesses. Thanks to years of fruitful research, major gains have been made in understanding and treating the various forms of depressive illness. In fact, with appropriate treatment, approximately 80 percent of even serious depressions can be successfully alleviated.
The bad news is that most people with a depressive illness do not seek treatment, many because they do not recognize that they have a treatable illness. That is why the National Institute of Mental Health (NIMH) is sponsoring a national educational campaign about depressive illnesses. Called Depression/Awareness, Recognition, and Treatment (D/ART), the campaign’s goal is to reduce unnecessary suffering by encouraging Americans with depressive illnesses to get appropriate treatment. Thus, the D/ART campaign is directed toward providing health care practitioners, mental health specialists and the general public with the latest treatment information.
Elizabeth, who once successfully balanced the demands of a career, marriage, and motherhood, can hardly get out of bed these mornings. The simplest chores seem impossible. Thinking and talking are difficult. Former pleasures—making love, eating good food, going to the theater with friends—are no longer enjoyable. She is tired all the time, but has trouble sleeping. Nothing has changed in her life to explain the way she has changed. Her husband is getting impatient, her children are feeling neglected, and her boss is threatening to replace her. lots of stress. Like Elizabeth, Nicole feels sad, guilty, and hopeless, but unlike Elizabeth, she sleeps and eats too much.When Luis’s company changed hands, he lost his job. The search for a new position proved frustrating and demoralizing. Luis finally got a job. He doesn’t like it, but he is afraid to leave. Now he feels sad and tired all the time. He finds it difficult to think clearly or act decisively. His unhappiness has spread to other areas of his life. Even his wife and children do not make him feel happy anymore. Luis believes his problems are his fault and that he should have been able to make the best of the situation. Fearing others also would view him as being “weak,” Luis won’t talk to anyone about his feelings and tries to drown his overwhelming sadness in alcohol.
Michael is on an emotional roller coaster. Sometimes he’s so low, he feels that suicide is the only way out. At other times, he thinks he can conquer the world. Unfortunately, when he’s feeling most invincible he behaves irrationally, going on spending and traveling sprees, staying up all night and talking ceaselessly.
Hattie is 75 years old. Three years ago, her husband of more than 50 years died. Shortly thereafter, her last living sibling— her sister—also passed away. Since t then she has become confused and forgetful, and appears satisfied to sit in one place staring into space for hours on end. Her children are concerned that their once alert and active mother has be come senile.
Elizabeth and all the others described above are suffering from a depressive illness. They are not lazy, misanthropic, senile or unusual. They cannot “snap out of it” or control their symptoms. They are ill and so are 10 million other Americans: Depressive illnesses are among the most prevalent of the mental disorders, affecting people of all ages, socioeconomic classes, races and cultures. Fortunately, depressive disorders are also among the most responsive to treatment; almost 80 percent of all serious depressions can be successfully alleviated. Nevertheless, relatively few victims of depression seek help.
Too many people suffer needlessly, not recognizing that their pains and aches, their exhaustion and irritability may be symptoms of an underlying depression. Luis, for example, didn’t seek help because he attributed his symptoms to personal weakness. His depression was finally recognized when, at his supervisor’s insistence, he underwent a complete clinical evaluation. Appropriate diagnosis and treatment have given Luis a new lease on life. He is no longer burdened with the symptoms that interfered with his ability to work and to enjoy life. Further, he is free of the guilt he felt for having such symptoms.
Elizabeth, like many others, put off getting help because she hoped her “blues” would go away. Months went by, but her mood did not lift, the exhaustion did not abate, and her feelings of hopelessness and worthlessness intensified. She began to think about suicide as a way of escaping her intense emotional pain. Luckily, her husband brought her to a physician who suspected depression and questioned her closely. When she admitted her suicidal feelings, he had her hospitalized and ordered a complete physical and psychiatric evaluation. A diagnosis of clinical depression led to treatment with an antidepressant combined with psychotherapy. Within a few weeks, she was released. Within a few months, she was back to being the person she used to be. Elizabeth thought it was a miracle, but her doctor said it was thanks to modern medical science.
Depressive illnesses should not be confused with the transient feelings of unhappiness that everyone experiences— the periods of sadness associated with unhappy events and failures, or the emotional letdowns that occur commonly around holidays. Nor should depressive disorders be confused with the intense grief brought about by the loss of a loved one. Sadness and grief are normal and temporary reactions to life’s stresses; time heals, the mood lifts, and people continue to function.
In contrast, individuals afflicted with a depressive illness do not feel better for months, sometimes for years. Depressive illnesses affect feelings, thoughts, and behaviors. Their symptoms include:
Anyone who experiences four or more of the above symptoms for more than two weeks, or whose usual functioning has become impaired by such symptoms, may have a depressive illness that should be treated.
There are several forms of depressive illnesses.
In some people, depressive symptoms begin suddenly and seem to have no relation to what is happening in their lives. With no apparent reason, they can no longer function as usual. Like Elizabeth, they are experiencing an episode of clinical depression. In Elizabeth’s case, she was diagnosed as having a major depressive episode because her symptoms were severe.
Some mental health experts suggest that the key feature of an episode of clinical depression is change—the former man about-town loses interest in women; the once social woman becomes reclusive. Furthermore, the change persists. Without treatment, the loss of interest in sex, food, or work, the changes in sleep patterns or mood, or other symptoms experienced by clinically depressed people may continue for months, even years. Although some people have only a single episode of clinical depression in a lifetime, it is more commonly a recurrent disorder. The more recurrent forms of clinical depression can be treated with maintenance medication to prevent further episodes.
Clinical depression also can occur following a loss, such as happened to Hattie and Luis. Or a woman may experience a clinical depression after giving birth, a condition sometimes referred to as postpartum depression. It is not unusual for important life events to be associated with transient, mild depression, whereas clinical depression is manifested by dramatic and persistent behavioral change.
However, some depressions are not signaled by behavioral change. People like Nicole seem to be depressed all their lives. Their symptoms aren’t as severe as Elizabeth’s, but drag on for years, keeping victims from ever feeling really well. They are suffering from dysthymia, a disorder once called neurotic depression. Some people with dysthymia also have episodes of major depression, their symptoms becoming dramatically more severe for awhile and then returning to their usual reduced level. These people are said to have double depression; that is, dysthymia plus major depression. Individuals with double depression are at much higher risk for recurring episodes of major depression, so careful treatment and follow-up are very important.
Michael is a victim of bipolar depression, also called manic-depressive disorder. He experiences alternating bouts of depression and mania. When depressed, individuals like Michael experience the symptoms associated with major depression. In addition, when in a manic phase of the cycle, they typically have:
Further, individuals, when manic, tend to overlook the painful or harmful consequences of their behavior. They may incur horrendous debts, behave promiscuously, make poor business decisions, break the law and land in jail, or lose friends, family, and employment.
In extreme cases, individuals with bipolar illness may experience thought disorder, jumping from one idea to another with no apparent connection, sometimes to the point of delusions and hallucinations.
Delusions are not limited to mania, however. When a clinical depression becomes especially severe, delusions are not uncommon; depressive delusions represent exaggerated feelings of helplessness, hopelessness, or guilt, such as feeling responsible for all the evil in the world.
Clearly, depression comes in various forms, sometimes referred to by various terms. Depending on whether a patient is talking to a clinician, researcher, or other mental health specialist, his or her illness may be referred to as clinical, major, melancholic, unipolar or endogenous. These differing terms can be confusing if the patient doesn’t realize that they are overlapping and not mutually exclusive.
The term “clinical” is a general term applied to any depression where symptoms are severe and lasting enough to require treatment. “Major” indicates a clinical depression that meets specific diagnostic criteria as to duration, functional impairment, and involvement of a cluster of both physiological and psychological symptoms. “Melancholic” is a severe form of major depression typified by a set of physiological symptoms which respond to antidepressant medications or electroshock therapy. “Unipolar” means that the individual suffers from major depression, but not from manic-depressive disorder, which is called “bipolar” illness. “Endogenous” is used to designate forms of depression manifested by a cluster of the more biological symptoms, such as sleep disturbance and weight loss. Moreover, patients may receive more than one diagnosis since depression is often associated with other disorders, such as alcoholism, anorexia, anxiety, and obsessive-compulsive disorders.
Diagnosing depression is of major importance to patients, clinicians and researchers, as this is the first step in the treatment process and in meeting the overriding concern of the patient to get well. Severe depression, however, can actually keep its victims from seeking needed help. Some lack the energy or hope for the future that is needed to take the initiative and some view their symptoms as punishment or their own fault. This can be especially true if family and friends take this view.
In fact, severe depression is an illness just as surely as are diabetes and heart disease. Family and friends should encourage a depressed person to seek expert evaluation. Such an evaluation will help diagnose the patient’s condition and indicate the treatment(s) that may be most useful. If the person is suicidal, an appropriate diagnosis and treatment may be lifesaving.
A complete clinical evaluation will involve 1) a physical examination which includes a neurological examination and lab tests, 2) a medical and psychiatric history, and 3) a mental status examination.
A physical examination is needed to rule out disorders, such as thyroid disease, anemia, or recent viral infection, that produce symptoms similar to those found in a depressive illness. A complete medical workup involves routine lab tests, a thyroid function test, and blood counts.
A neurological examination will involve checking a patient’s coordination, reflexes, and balance to rule out a neurologically based disorder that may be causing the symptoms. On occasion, the physician may want additional information and call for an electroencephalogram (EEG) or one of the brain scanning techniques that can provide insight into brain structure or function.
A complete history is a vital part of an evaluation. The doctor will typically ask about the reasons for the visit and carefully discuss all of the patient’s symptoms, taking care to ask about symptoms the patient might not mention. Of concern to the doctor will be the severity of symptoms, functional impairment, and the possibility of suicide. The doctor probably will ask when symptoms started, how long they have lasted, whether they are getting better or worse, and what may have precipitated them—serious loss, illness, divorce, or whether they occurred out of the blue.
A medical history also entails questions about previous episodes of depression and/or mania and treatments received, including details about medications, such as dosage and precise periods of use. Further, the doctor will inquire about the patient’s use of alcohol and other drugs, prescribed or recreational. Family history is also important. This would include questions about similar illnesses in relatives and the treatments they had received.
When people with depressive illnesses are poorly able to communicate or to give detailed information about their past, family members are often interviewed about the history and development of the illness.
Finally, a mental status examination will involve observations of whether the patient’s thought processes, speaking patterns, and memory seem to be affected as often happens during depressed or manic episodes.
A thorough evaluation is time-consuming, often taking several hours. Patients who express hopelessness, who have specific suicide plans, or whose depressive illness is complicated by alcoholism are particularly prone to suicide and may require hospitalization. Even after treatment has begun, a depressed person may need considerable encouragement from friends and family to continue. It takes time for treatments to alleviate symptoms— several weeks in the case of medications and several months with psychosocial treatments. Sometimes different types of antidepressants have to be tried to find the one that works best. Without being offered false hope, the depressed person can be informed that many different types of treatment are available and if one does not work, others are likely to be effective.
The possibility of suicide is the most serious complication of depressive illnesses. Feelings of worthlessness and guilt, combined with a special kind of psychic pain, may overwhelm the individual so that he or she feels unable to go on or unfit to live. Sometimes these feelings remain just thoughts, and at other times they lead to suicidal attempts.
Not all those suffering from depressive illnesses attempt suicide, nor are all those who attempt suicide suffering from a depressive illness. It is estimated that 15 percent of depressed persons may eventually commit suicide and, among suicide victims, more than half are suffering from a depressive illness. The person hospitalized for depression at some time in his or her life is about 30 times more likely to commit suicide than is the non-depressed person, with the greatest risk during or immediately following hospitalization. A family history of suicide is an additional risk factor.
The possibility of suicide increases with advancing age. In recent years, however, there have been alarming increases in suicide among young adults. Approximately twice as many women attempt suicide; however, men are more likely than women to actually kill themselves.
Studies of families with histories of an unusually high incidence of depressive illnesses have led scientists to conclude that a predisposition to some forms of the illness, particularly those with recurrent episodes, could be inherited. Recently, direct evidence of genetic vulnerability to manic-depressive illness has been found: Family members who have the illness have, in a specific chromosomal region, genes that are different from the genes of those who do not get ill. The variant genes are called genetic markers because they are inherited along with vulnerability to the illness.
Long before sophisticated gene-mapping technologies provided evidence for genetic vulnerability, research with twins indicated that inheritance plays a role. Scientists have shown that if one identical twin suffers from depression or mania, there is a 70 percent likelihood that the other twin also will be afflicted. Among non-identical twins, however, as with siblings, parents, or children of the afflicted person, the risk decreases to about 25 percent. Since identical twins have all their genes in common, and siblings and other first-degree relatives have only half in common, the affliction rates attest to genetic involvement.
Studies of adoptees carried out in New York, Brussels, and Denmark also provided evidence of a genetic factor. The New York/Brussels researchers identified two groups of adopted individuals: those who had been diagnosed as having a depressive illness and those who did not. They then compared the incidence of diagnosed depression in biological and adoptive relatives. They found that biological relatives of adoptees with depressive illnesses had higher rates of major depressive illnesses, alcoholism, and suicide than did relatives of adoptees who did not have a mental illness.
The Denmark study, which included first- and second-degree relatives of both biological and adopting families of depressed individuals, found a higher concentration—three times greater—of depressive disorders among biological relatives than was found among the adopting families.
While the above findings give credence to a genetic vulnerability, environmental stresses and biochemical dysfunctions also may play a role in the onset of a depressive illness.
Some 30 years ago, physicians first observed that certain medications had strong mood-altering properties. Depression was observed in patients taking reserpine, a drug to control blood pressure. In contrast, isoniazid, used to treat tuberculosis, was associated with euphoria in some patients and was soon tested as a potential antidepressant.
The implications of these observations—that mood disorders could be a function of a biochemical disturbance and could be treated with drugs— prompted clinical and laboratory studies that revolutionized the concept and treatment of mental disorders. Three types of drugs, the tricyclics, the MAO inhibitors, and lithium, have been successfully used to alleviate symptoms of depression for many years. New types of antidepressant drugs are also currently available with additional ones being developed and tested regularly.
How these medications work to alleviate depression and mania is being intensively studied. Over the years, hypotheses about drug function have been developed and modified. Central to most hypotheses is the role of neurotransmitters—chemical “messengers” that transmit electrical signals from one nerve cell to another across the synapse (the space between nerve cells). By means of this chemical signaling, neurotransmitters set in motion the complex neural interactions that affect our behaviors, feelings, and thoughts.
Originally it was hypothesized that depression and mania were associated with improper functioning of a particular type of neurotransmitter, the biogenic amines. Specifically, it was thought that depression was related to a deficit of neurotransmitters— either norepinephrine or serotonin—at critical synapses in the central nervous system. By implication, mania was related to an excess of neurotransmitters. More recently, it has become evident that a third biogenic amine, dopamine, as well as other neurotransmitter systems, may also be involved in mood disorders.
Another area of substantial research has been stimulated by the observation that patients with Cushing’s disease suffered from depressed mood and, further, that this disease was associated with an excess of the steroid hormone cortisol. These observations led to measurement of cortisol in the blood or urine of depressed patients and it was found, in fact, that approximately 50 percent of depressed patients had elevated levels which returned to normal when they recovered. Capitalizing on the knowledge that dexamethasone, which normally suppresses production of cortisol, does not do so in Cushing’s patients, mental health investigators have systematically evaluated dexameth asone suppression in depressed patients. Using the dexamethasone suppression test, developed to diagnose Cushing’s disease, researchers found that a significant population of bipolar and unipolar depressed patients show the abnormal pattern of cortisol non-suppression. However, this test has proven too nonspecific to be a useful diagnostic tool for depression: many non-suppressors have disorders other than depression and many depressed persons are not identified by the test. In fact, there are not yet definitive biological tests to diagnose depression or predict response to a given treatment.
Sleep studies, however, hold some promise as a biological marker. Sleep patterns of both unipolar and bipolar depressed patients are different from those in persons who do not have a mood disorder.
For example, the rapid eye movement (REM) phase of sleep associated with dreaming occurs earlier in people with mood disorders. This phenomenon is referred to as shortened REM latency. Persons with mood disorders also have more eye movements during REM sleep, less deep or slow-wave sleep, and more problems staying asleep.
It is not yet known whether the “biochemical disturbances” associated with depressive illnesses arise spontaneously or whether they are precipitated by stress, trauma, physical illness, or some other environmental condition.
Personal losses, financial problems, physical illness, midlife crises, sex role expectations, and psychosocial phenomena such as personality, upbringing, and negative thinking style have been cited as contributors to depressive illness. Any change, serious loss, or stress—a divorce, the death of a loved one, the loss of a job, or move to a new home—can trigger depressive feelings. In most cases, such feelings are temporary, but some people—who may have a preexisting vulnerability— develop a depressive illness. Their sad mood and depressive symptoms do not abate. They need treatment.
Trying to sift apart the environmental, biological, and genetic causes of depressive illnesses is extremely challenging. Confusion about terms— depressive feelings vs. depressive illness—add to the problems. For example, depressive feelings and demoralization are certainly more common among the poor, the deprived, and those lacking social supports, and yet it is not clear whether depressive illnesses are more prevalent among victims of such environmental stressors.
Some scientists have drawn inferences about the environmental/psychosocial factors associated with depressive illnesses from data collected during an extensive NIMH survey of mental illness in the United States. More than 18,000 randomly selected adults, aged 18 and over, living in five U.S. communities, were interviewed in their homes with the use of a specially-designed questionnaire. Included in the survey were both persons who had been treated and never treated for a mental illness. More than 15 percent of those surveyed had a diagnosable depressive illness.
The study found that women as compared to men were at greater risk for major depression at every age. In contrast, bipolar (manic-depressive) disorder, which is much less prevalent than major depression, occurred as frequently in men as in women.
The youngest persons surveyed appeared most vulnerable. The highest rates of major depression were found in people ages 18-44 and in those who were separated, divorced, or unhappy in their marriage.
The survey indicated an apparent increase in rates of depression in persons born since World War II, the “baby boom” generation. Many reasons for the increase have been suggested, including increased drug and alcohol use and decreasing employment opportunities. Other studies have shown that family history of depression (depression in biological relatives including parents, brothers, sisters, or children) also increases the risk of bipolar disorder and major depression.
After age 45, the occurrence of major depression and bipolar disorder declined somewhat, but dysthymia—a mild, chronic depression—remained at a high level, especially in women in the older age group.
The stresses facing women today—major responsibilities at home and work, single parenthood— might seem to contribute to their high rates of depression. Yet some experts argue that women are not more vulnerable to depression than men, but just deal with their symptoms differently. Women, they say, are more apt to admit feelings of depression and seek professional assistance, whereas men may be socially conditioned to repress such feelings or to bury them in alcohol, as reflected in the higher rates of alcoholism among men.
On the other hand, social conditioning also has been cited as contributing to a higher incidence of depression among women. One theory, which remains controversial, suggests that young girls are taught to be helpless and therefore are vulnerable to depression when faced with the realities, problems, and decisions of adulthood.
In addition to the psychosocial explanations for higher rates of depression among women, hormonal functioning also is considered a possible influencing factor. Postpartum depressions, which range from serious incapacitating episodes to transient blues following childbirth, seem to point to a hormonal component, but the biological mechanism that would explain hormonal involvement has yet to be discovered.
Menstrual cycles have been associated with depressed feelings, irritability, and other behavioral and physical changes in women. Referred to as premenstrual syndrome, this disorder has become the subject of recent research and much controversy about its causes, implications, and relation to depressive disorders. The answers will no doubt emerge as researchers apply their expertise to this long-ignored condition.
At one time, mental health experts believed that women who experienced depression during change of life were suffering a special kind of depressive illness referred to as involutional melancholia, a diagnosis no longer in use. Research has shown that depressive illnesses at menopause do not differ from those experienced at other ages and that women most vulnerable to change-of-life depression typically have a history of past depressive episodes.
Similarly, close examination of the facts casts doubt on the “empty-nest” syndrome as an explanation for depression in older women. The theory is that when children grow up and leave home, women who have devoted their lives to rearing them feel useless, or no longer needed, and bereft of ego-supporting activities, much in the way that some men respond to retirement. However, the lack of increased rates of depression among women at this stage of life suggests that most women do not get depressed when children leave home.
Whether the causes of depression are biochemical, psychosocial, or both, highly effective treatments are available. In most cases, individuals no longer need suffer or remain nonfunctional due to symptoms of depression.
Of all the mental disorders, depressive illnesses are among the most responsive to treatment. Advances in treatment have helped to alleviate and prevent the symptoms and complications of depression, enabling most persons to lead normal lives. Many different types of treatments are available, and the mode chosen depends on the diagnosis, and severity and pattern of symptoms. The three basic types of treatment— drugs, psychosocial therapy, and electroconvulsive therapy—may be used singly or in combination.
There are numerous antidepressant medications available and more are being developed all the time. Three categories of drugs are most often prescribed: tricyclics, monoamine oxidase inhibitors (MAOIs), and lithium. The tricyclics and MAOIs alleviate a wide range of symptoms of depression and anxiety. Lithium is prescribed to control manic-depressive illness and the more recurrent forms of unipolar depression.
There are many forms of tricyclics and MAOI antidepressants, each with slightly different mechanisms of action or side effects. Since response to drugs varies with each individual, it may be necessary to test a sequence of several different drugs or combinations of drugs to determine which works the best with the fewest side effects. Most antidepressant side effects, such as dry mouth, drowsiness, and constipation, occur early in the treatment and subside as the body adjusts.
For the typical serious depression, tricyclics or newer heterocyclic drugs (that have four or more chemical rings to their structure) are probably the first-choice medications. They alleviate many depressive symptoms, including loss of appetite and weight and problems sleeping. However, for those depressed patients who experience increased appetite and sleepiness, the MAOIs are also likely to be useful. In addition, depressed people who have high levels of anxiety, hypochondria, and phobic characteristics may respond well to MAOIs. Those with obsessive-compulsive symptoms are likely to respond to a new drug, fluoxetine, which selectively acts on serotonin. Individuals taking MAOIs must not eat certain smoked, fermented, or pickled foods. A full list of foods to be avoided will be provided by the doctor.
Lithium is generally most effective in reducing the frequency and severity of manic-depressive cycles. However, some persons experiencing only depressive episodes, particularly those who have a family history of mania, also respond favorably to lithium.
In a recent NIMH study, at least 70 percent of the manic-depressive patients maintained on lithium stopped having episodes or had fewer, shorter, or less severe ones. Because of its effectiveness when taken prophylactically, lithium is said to be to manic-depressive illness what insulin is to diabetes.
There are some manic-depressive patients, however, who do not respond to lithium but do respond to a drug called carbamazepine. Patients who have rapidly changing cycles, for example, can generally be helped by the addition of carbamazepine to lithium.
Maintenance on medication is essential for persons with recurrent forms of depression, particularly manic-depressive disorder and recurring episodes of major depression. Such continuous treatment can offer essentially normal functioning to those whose lives might otherwise be painful beyond endurance. For many patients, it is essential that they receive psychotherapy to help them stay on their medication and to deal with the psychological problems typically associated with their illness.
Psychosocial therapies come in many variations and are offered for groups, families, couples and individuals. There are “talking” therapies during which problems are discussed and resolved through the emotional support, insights and understanding gained from the verbal give-and-take. Other therapies concentrate on behaviors: patients are taught to be more effective in obtaining rewards and satisfaction through their own actions. Some therapies examine the past, seeking resolution of present problems by shedding light on earlier experiences. Others focus strictly on current conflicts and interpersonal problems.
Currently, among the most widely used forms of psychosocial therapy are those referred to as psychodynamic. Such therapies are based on the assumption that internal psychological conflicts (e.g., wanting both to be independent and cared for, or feeling angry while believing that one should always be kind and loving) are at the heart of the patient’s disorder. Resolution of such conflicts is thought to be essential to successful treatment. Unresolved conflicts are often rooted in early childhood, with many conflicts evolving from child-parent relationships. A key aspect of the treatment involves bringing the conflict into the therapeutic situation where it can be dealt with and resolved. Psychodynamic therapy is typically open-ended in terms of time, but new short-term versions also are used to treat clinical depression.
Short-term therapies, typically lasting 10 to 20 weeks, focus on specific areas of concern that are thought to be causing the depression. In some cases, this may be interpersonal problems—disturbed social relationships that cause depressive symptoms which, in turn, exacerbate these disturbed relationships. Thus, a dysfunctional cycle is set up and perpetuated. Other short-term therapies focus on the negative styles of thinking and behaving not uncommon among depressed persons. These therapies try to help patients attain a more realistic view of themselves and their worlds and to encourage behaviors that will engender positive responses from others.
For some patients, the most effective treatment is a combination of psychotherapy and antidepressant medication. Thus, patients whose depression persists in spite of psycho- therapy should be evaluated for treatment with medication.
With the availability of antidepressant drugs, use of electroconvulsive therapy (ECT) has declined. Although ECT has received unfavorable publicity, it continues to be the most effective treatment for major endogenous or delusional depression. Its use should be seriously considered in the following circumstances: the individual is severely depressed (especially if delusional), is at high risk for suicide, is severely malnourished, does not respond to drugs, or, as commonly occurs among the elderly, cannot take drugs because of a medical problem such as a heart condition.
With current ECT practice, the patient is briefly put to sleep with an intravenous anesthetic, ensuring that the procedure is neither experienced nor remembered. A muscle relaxant is administered to minimize muscular response during the treatment.
Electrodes are placed either on both sides of the scalp (bilaterally) or on the one side of the scalp (unilaterally) on the “nondominant” side of the brain (usually the right side). There is substantial evidence that unilateral electrode placement over the nondominant hemisphere produces less disruption of memory and less confusion following treatment. However, there is also some evidence that unilateral nondominant placement may be less effective or require more treatments than bilateral placement, which often requires 7 to 12 treatments.
With bilateral treatments in particular, patients experience transient memory loss for events immediately surrounding the treatment. After ECT is ended, memory for past events and the ability to learn new information is typically unaffected.
As noted previously, there are different forms of depressive illnesses and different types of treatment. Choice of treatment typically depends on the pattern, severity, and persistence of symptoms, and the history of the illness. When symptoms are severe or last longer than two weeks, a complete diagnostic evaluation is required to determine which treatment(s) to use.
The following briefly describes the types of therapeutic approaches that would most likely be taken under the conditions outlined below. However, treatments will be modified and adjusted to suit the individual needs of each patient. Close monitoring is essential to track a patient’s progress and response to medications that may be prescribed.
large number of individuals experience brief depressive episodes with relatively mild symptoms lasting only days or a week. These episodes may cause personal distress and discomfort, but do not interfere with the ability to function at work or at home. Such episodes often improve without intensive treatment, but will be helped by counseling, psychotherapy or antianxiety and tranquilizer medication.
If symptoms continue for more than two weeks and include anxiety, sleep difficulty, loss of interest and pleasure in usual activities, difficulty concentrating, headache, backache or other bodily complaints and there is some interference with work and family activities, (the individual, however, can still carry out usual responsibilities), a comprehensive diagnostic assessment, including medical examination, is essential. The patient and therapist have a choice of medications, particularly tricyclic antidepressants and/or forms of brief focused psychotherapy. Often, however, combinations of medication and psychotherapy are most effective.
More intensive treatment is called for when depression continues for many weeks and involves thoughts of death, suicidal attempts, impaired judgment, and marked mood swings. For these types of depression, antidepressants or ECT are generally required.
Most depressed people can be treated as outpatients; however, severe episodes—particularly involving serious weight loss, marked agitation, or suicidal intent—may require brief periods of hospitalization. During hospitalizations, careful evaluations can be done, the patient can be protected, and biological and psychosocial treatments initiated.
A significant number of individuals experience depressive symptoms which persist for months or even years. Often these symptoms appear to be part of the individual’s personality. Rather than suffering in silence or accepting these symptoms as basic characteristics, individuals should consider intensive treatment, including medications.
Normal behaviors vary so much from one childhood stage to another that it sometimes is difficult to know whether a child is suffering from depression or just going through the terrible twos, sulky sevens, or the trying teens. Also, temporary interludes of depression, when things go wrong, are just as common among children as adults.
But a depressive disorder may be indicated if symptoms similar to those seen in depressed adults— sadness, apathy, sleeping and eating disturbances— continue for several weeks. In cases of severe depression, children may also experience feelings of hopelessness and despair, and harbor suicidal thoughts.
Childhood depression may be unrecognized or misdiagnosed when depressive symptoms are mixed with other types of behavior, such as hyperactivity, delinquency, school problems, or psychosomatic complaints. A closer examination of a child’s thinking and functioning may reveal underlying depression and feelings of worthlessness.
The loss of love or attention from someone on whom a child is dependent for care and nurturance may precipitate a depressive episode. The loss may be caused by the death or prolonged absence of the beloved persons. In some cases, the caretaker remains physically present but for some reason withdraws from the child.
Deprecation and rejection of the child by a caretaker also are important factors in many cases of childhood depression. Most childhood depression, however, is not caused by a single precipitating incident or factor, but is usually associated with genetic vulnerability and ongoing environmental stresses.
Children identified as especially vulnerable to depression include those of manic-depressive parents or of parents hospitalized for a chronic physical illness. Hospitalized children, particularly those with a chronic illness, are also at risk.
The importance of treating depressed children has been shown by several studies which indicate that untreated childhood depression may lead to subsequent problems in adolescence and adult life.
Parental and family therapy are commonly used to help the younger depressed child. Through providing emotional support and guidance to family members, the mental health professional can facilitate the child’s recovery Children over 8 years of age usually participate in family therapy. In some situations, individual treatment may be appropriate for older children.
Medications, such as antidepressants or lithium, can be important in the treatment of children, especially for the more serious and recurrerent forms of depression.
Depressive illnesses appear to be occurring more commonly among teenagers today than in the past. Many young people, whose symptoms are chalked up to the “normal adjustments” of adolescence, do not get the help they need. Some become so despairing—believing their problems insoluble— that they try to kill themselves, and many actually do so. During the past three decades, suicide among adolescents has increased 300 percent.
While depression is not the only cause of teenage suicide, it is a major one and certainly the cause of much pain as well. Depressed adolescents, like depressed people in any age group, can experience feelings of emptiness, anxiety, loneliness, helplessness, hopelessness, guilt, loss of confidence and self-esteem, and changes in sleeping and eating habits. In addition, they often “act out.” That is, they try to “cover” their depression by acting angry or aggressive, running away, or becoming delinquent.
Manic-depressive disorder in adolescents is often manifested by episodes of impulsivity, irritability, and loss of control alternating with periods of withdrawal. This treatable disorder typically goes unrecognized when it is assumed that such storminess is natural to adolescence.
Since adolescents are noted for their quickly changing moods and behavior, it may take careful watching to see the differences between a depressive disorder and normal behavior. The key to recognizing the depressive disorder is that the change in behavior lasts for weeks or longer. Any youngster who has four or more symptoms of depression for longer than a few weeks, or who is doing poorly in school, seems socially withdrawn, uncaring, overly impulsive, and no longer interested in activities once enjoyed, should be checked for a possible depressive illness. Depression in adolescents can and should be treated.
The wide range of estimates of occurrence of depression among older populations—from 10 percent to 65 percent—attests to the difficulties of diagnosing depression in an elderly person. Symptoms of depression are often misdiagnosed as senility (organic brain syndrome) or mistaken for the everyday problems of the aged.
For example, the memory loss, confused thinking, or apathy symptomatic of senility actually may be due to depression. On the other hand, the early awakening and reduced appetite typical of depression are common among many older persons who are not depressed. While there is some controversy about how much clinical depression occurs among the elderly, it is known that on self-report tests, they acknowledge more of the symptoms of depression than any other age group. They also commit suicide at higher rates than other groups.
Nevertheless, and further complicating diagnosis, elderly persons rarely admit feelings of depression, even though they often have much to be depressed about—poor health, loneliness, poverty, or the death of a spouse or other beloved family members or friends. Often they incorrectly attribute their depressive symptom to physical ailments, and either ignore them or seek inappropriate treatment.
On the other hand, depression does accompany many of the illnesses that afflict older persons, such as Parkinson’s disease, cancer, arthritis, and the early stages of Alzheimer’s disease. Treating depression in these situations can reduce unnecessary suffering and help afflicted individuals cope with their medical problems. Medications taken by older persons or inadequate diets, often a problem of older individuals who live alone, can also cause depression as a side effect.
Careful observation by a knowledgeable person, in addition to sophisticated medical evaluation, may be necessary to recognize the depressed older person. A physician attempting to differentiate between senility and depression may call on family members or longtime friends for information on the patient’s history, since the onset of depression is usually more sudden than the slow and gradual process of senility. Also, the individual with organic problems typically minimizes loss of mental function such as memory, while the depressed person exaggerates the loss.
Treatment of the elderly, if antidepressants are indicated, can be complicated by physical problems in addition to diagnostic problems. The older person is more apt to have a complex set of physical ailments for which various drugs are taken. Simultaneous use of drugs, including alcohol and over-the-counter, borrowed drugs, or prescribed drugs can be dangerous. Before prescribing an antidepressant, a physician must carefully consider all other drugs used by the patient, particularly those for heart conditions, to avoid unwanted side effects. Also, because the elderly metabolize drugs more slowly than younger people, smaller doses are usually given, and the prescribing physician needs to carefully consider and monitor the dosage and efficacy of antidepressants.
Difficulties aside, appropriate treatment of the depressed older person, as with younger individuals, can bring relief from suffering and offer a new lease on life and renewed productivity. There is no justification for anyone of any age to suffer needlessly from depression because of lack of treatment.
Perhaps the most important thing family and friends can do is to encourage the depressed person to get appropriate treatment. The very nature of depression—the feelings of helplessness, hopelessness, and worthlessness— can keep the depressed person from seeking help. When symptoms linger beyond a reasonable time, or if there seems no apparent reason for the individual’s persistent feelings of unhappiness and gloom, the observant and caring friend or relative should help the depressed person get professional assistance.
Family and friends can also provide much needed love, and encouragement. Depression destroys self-esteem and confidence, and family and friends can help the depressed person feel worthwhile by applying the following “DOs” and “DON’Ts”:
DO
DON’T
In addition, friends and family can help by keeping the depressed person busy and active. Depression tends to feed on itself, and a moderately depressed person becomes apathetic and inactive leading to more depression, more withdrawal, and more inactivity, resulting in vicious cycle. Gentle assertiveness may be required to stand by the depressed person, particularly if the individual is withdrawn and rejecting.
Depression typically involves strong feelings of guilt, and it is important that family and friends do not compound such feelings by blaming the individual for his or her symptoms. Depressed people often arouse anger in others, and it is tempting to become impatient, to tell the depressed person to snap out of it, or to indicate that depression is a sign of weakness. The depressed person is in pain and needs understanding and help.
Also, the possibility of suicide must always be considered in cases of depression. Though a depression may appear relatively mild, it does not exclude the possibility of suicide. Sometimes seemingly mild depression has much deeper roots. Nor is it true, as many people believe, that a person who talks about suicide will not attempt it. Those who attempt suicide often appeal first for help by threatening to do so.
Even when there appears little or no danger of suicide, a mental health professional should be consulted when a serious depressive disorder is suspected. The earlier the depressed person receives help, the sooner the symptoms are alleviated and the speedier the recovery.
Depression is the most treatable of all the mental illnesses. Individuals no longer have to suffer its debilitating symptoms. With modern treatment methods, they can return to full and productive lives.
Family physicians, clinics, and health maintenance organizations. usually the first health contact of a depressed person, can refer to mental health specialists for evaluation and treatment. They also can cooperate in the patient’s treatment by providing needed medications.
Community mental health centers provide assistance at a cost commensurate with the patient’s ability to pay. Check the yellow pages of your phone book to find if there is a community mental health center in your area.
Some hospitals and universities have special research centers that study and treat depression. Anyone interested in participating in a study can contact a center nearby to see if such research is being conducted there.
Information about centers that specialize in treating depressive disorders can also be received by writing to The National Foundation for Depressive Illness, 20 Charles Street, New York, New York 10014.
If information on private sector practitioners is preferred, references can be received from your local Mental Health Association (MHA). The national MHA office is situated at 1021 Prince Street, Alexandria, Virginia 22314-2971.
Another consumer organization, specifically devoted to assisting individuals with depressive disorders, has chapters in various locales around the country: National Depressive and Manic Depressive Association, 53 W. Jackson Blvd., Rm. 618, Chicago, Illinois 60604.
The National Alliance for the Mentally Ill (NAMI), an organization of family members and patients, provides mutual support for its members, information about serious mental illnesses to the public, and advocates for more research and services on behalf of the mentally ill. NAMI has chapters in every state. For more information, write to the national office: NAMI, 2101 Wilson Boulevard, Suite 302, Arlington, Virginia 22201.
The National Institute of Mental Health is sponsoring a national education program about depressive illnesses called D/ART, which stands for Depression/ Awareness Recognition, and Treatment. D/ART is designed to inform primary health care providers, mental health specialists, and the general public about the most up-to-date treatments for depressive illnesses in order to reduce unnecessary suffering for the millions who are afflicted. D/ART is a cooperative Federal government/private sector effort, involving representatives from community and health organizations, the media, business, and industry.
For more information about D/ART write to: D/ART, National Institute of Mental Health, Room 15C-05, 5600 Fishers Lane, Rockville, Maryland 20857.
Source: National Institute of Mental Health (NIMH).
U.S. Department of Health and Human Services
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