Out of the Shadows: Identifying and Healing Depression
By Nada Stotland,MD
(Dr. Stotland is a practicing psychiatrist, author, and
teacher; she is Professor in the Departments of Psychiatry and
Obstetrics/Gynecology at Rush Medical College, and Chair of
Psychiatry at Illinois Masonic Medical Center. Original
article, with additional material from "Depression:
serious, prevalent, treatable": AJ.Rush et al., Patient
Care, Feb.1994)
Depression is a confusing and
misunderstood term. We say we're "depressed" when we
have a bad day or even a bad hour. Then we chat with a friend,
take a bath, or watch a good television show, and we feel
better. This kind of "depression" is just a passing
mood, a familiar part of life. But depression is also the name
for a genuine illness, one that isn't necessarily caused by
bad news or irritating people. It sometimes comes on out of a
clear blue sky. Unlike everyday "depression," this
depression-the illness-doesn't respond to a pleasant
distraction or reassurance from a friend or relative. If you
have this sort of depression, your whole world will feel gray
or even black, even though you may be surrounded by things you
should be enjoying-things you used to enjoy.
True clinical depression changes
your appetite and your sleep patterns despite your best
efforts to eat properly and get rest. It makes you feel tired
and irritable, guilty and worthless, even though you know
you're really not a bad person. Worse, it can make you feel so
hopeless that you don't even feel it's worthwhile to look for
help. Meanwhile, your loved ones and your co-workers are
getting increasingly frustrated: "Why can't she snap out
of it? After all, everyone has bad days. She ought to be able
to cope."
COMMON AND COSTLY
If you have such feelings or have
had them, you're far from alone. Depression is an illness that
strikes one in four Americans at some time during their lives,
and women are affected two to three times as often as men.
Young women at home with preschool children are especially
vulnerable to depression, but it can strike at any age from
early childhood to extreme old age. The causes are equally
diverse. And, contrary to what many believe, women don't get
depressed just because they work outside their homes or
because they're going through menopause.
Depression is painful and debilitating. It complicates relationships and decreases productivity. The annual financial cost of depression is staggering. Every year in the U.S., depression accounts for $129.3 billion in medical care, lost lifetime earnings because of depression-induced suicides and especially lost earnings from lost work time. For the individual woman, it may seem all-consuming. A single episode of depression lasts 6 to 9 months if not treated. Moreover, one episode of depression can lead to another and then another, ever more frequently and severely.
Bleak as this description may seem,
the situation is far from hopeless. The good news is that
depression is very easily diagnosed and treated. Two-thirds of
people suffering from it can be cured by their first attempt
at treatment. Most of the remaining third can be cured by a
second or third attempt. There's no reason for anyone to
simply endure this painful and disabling illness.
The bad news is that 80% of
episodes of depression are not diagnosed and treated.
Primarily, that's because depressed people, their loved ones,
and even their doctors often fail to recognize the symptoms or
to realize that effective treatment is available. In fact,
because a depressed woman may seem to have no apparent reason
to be depressed, her friends and relatives may sometimes get
annoyed and actually withdraw their support.
DEPRESSION IS SERIOUS BUSINESS
When depression occurs in the midst
of serious illness or after a significant loss or
disappointment, loved ones and even some health-care
professionals may dismiss it as an inevitable response to the
person's situation. Because it's seen as a "natural"
consequence of these circumstances, the need for treatment may
be ignored. But other conditions arising from illnesses or
common events aren't viewed that way. For example, we always
treat a wound infection that occurs after surgery or a broken
leg resulting from a car accident. We would never just say,
"Oh, well, anyone would have an infection or a broken leg
under these circumstances."
Unfortunately, mental illnesses
such as depression carry a heavy stigma. They're associated
with being crazy, lazy, or weak. Psychiatrists, psychologists,
and other professionals who treat people for depression are
stigmatized, too; they're called "shrinks" or
"the men in the white coats" or worse. Even the
therapies are suspect. Some people are afraid that treatment
by a mental health professional consists only of mind-altering
drugs. They assume that medications used for depression are
something like the "uppers" sold on the streets.
Others assume that treatment consists of lying on a couch and
telling your childhood memories and sexual secrets to an utter
stranger who may have even stranger ideas about what has made
you ill.
Still others believe that mental
health professionals operate so arbitrarily that they can find
something wrong with anyone. Some people even believe mental
health medicine is not real medicine or science. After all,
psychiatrists and psychologists don't have x-rays and blood
counts and throat cultures to nail down a diagnosis the way
internists and surgeons do.
DEFINITIONS AND CRITERIA
All of these assumptions are wrong.
Today, the diagnosis of depressive illness is just as accurate
as, or more accurate than, most other medical diagnoses.
Depression is caused by a change in brain chemistry.
Antidepressant medications return that chemistry to normal;
they don't drug a depressed person into feeling good, just as
they cannot make a person who is not depressed more cheerful
or energetic. Modern treatment of depression makes use of
specific medications or specific counseling (psychotherapy),
or both, to help a depressed person overcome the negative
patterns that have intruded on her normal moods, thoughts, and
behaviors.
Extensive scientific research
indicates major depression is a disease that can be
diagnosed by establishing that, for most or all of every day
for 2 weeks, a person has experienced at least five of the
following ten symptoms:
A feeling of sadness, or periods of
crying.
Feelings of guilt, self-blame, or
worthlessness.
Changes in sleep pattern (for
adults, this usually means falling asleep but waking up
earlier than intended, and still tired; for adolescents and
young adults, it may mean sleeping much more than usual).
Changes in appetite and weight
(adults usually lose; younger depressed patients may eat more
and gain).
Decreased interest in sex.
Decreased ability to enjoy things
one used to enjoy.
Decreased ability to concentrate.
Decreased energy.
Feelings of hopelessness and
helplessness.
Thoughts of death and even suicide.
Some people suffer a milder and
more chronic form of depression called dysthymia {dis-THIGH-me-a},
which causes these same signs and symptoms, but fewer of them.
It's possible to have both major depression and dysthymia at
the same time, a condition called double depression.
Sometimes depression is named after the stage of life when it
occurs: an example is postpartum depression, which
sometimes occurs after childbirth. Manic depressive
illness is a condition in which episodes of depression
alternate with episodes of abnormally high energy and elated
or irritable moods.
Child birth does increase
susceptibility to depression. Many women go through a brief
period of heightened emotion and tearfulness a few days after
delivery. This episode of "baby blues" almost always
subsides without treatment. Caring for a new baby is
exhausting and distracting for most women, but only about 10%
of them will experience true clinical postpartum depression.
If a woman's symptoms persist or get worse, she should get
professional attention.
Children can have true depression,
too. Many cases of depression in children are also overlooked,
both because people want to assume that childhood is always a
happy time and because depressed children don't always act
quite like depressed adults. They may just withdraw into
themselves, so that all the attention in the family or the
classroom goes to more lively children. Or they may act up,
talk back, and become uncooperative, provoking parents and
teachers to punish them and make them feel even worse.
Depressed children don't know what it is that's troubling
them-and couldn't easily put it into words even if they did.
TREATMENT: WHAT TO EXPECT
While depression can generally be
treated without delving into subconscious memories and
conflicts, it's true that past and current experiences of
abuse, neglect, and trauma make a person more vulnerable.
Losing a parent during childhood increases susceptibility to
depression as well. Depression is not inherited, though there
is a genetic predisposition for it. Your heredity interacts
with your life circumstances. It can be difficult to get a
family history of depression, however, because the disease may
not have been diagnosed, or, if diagnosed, may have been kept
secret within the immediate family.
If you or someone you care about
has symptoms of depression, first have your primary-care
provider check to make sure they aren't being cause by another
medical condition, like a thyroid deficiency or a low blood
count. It's also very important to review with your doctor
every medication you're taking. Medications used for high
blood pressure, birth control pills, and other prescriptions
can be associated with depression in some people. Laboratory
tests are not necessary to make the diagnosis of depression.
Depression can be effectively
treated with specific antidepressant medications. There are
several classes of antidepressants (see "Medications to
Treat Depression"); patient and doctor together choose
one on the basis of cost, side effects, and other individual
factors. Your family doctor can prescribe treatment or refer
you to a specialist at any point. The most effective treatment
combines medication with psychotherapy, or "talking"
therapy, preferably a type of psychotherapy that focuses on
identifying negative thought and behavior patterns and helps
the depressed person substitute more accurate and optimistic
ones. Psychotherapy alone can treat milder cases of depression
effectively.
Psychotherapy can be provided by a
social worker, psychologist, specially trained nurse
practitioner, or other types of specifically trained
counselors. Medication can be prescribed by your family doctor
or by a psychiatrist. Two-thirds of patients with depression
will respond within several weeks to the first trial of
effective treatment. Others will require a change of dosage or
a different medication.
More complex treatment should be
provided or supervised by a psychiatrist. Psychiatrists are
medical doctors who have four additional years of training in
mental illnesses, and who can both prescribe medications and
perform psychotherapy. In a small percentage of cases,
depression may be so severe that it causes a person to lose
touch with reality, or to lose the ability or will to take
care of her basic needs. In such cases, it can be life
threatening. Electro-convulsive, or "shock," therapy
(ECT) can be lifesaving and effective in these cases. Though
the name sounds frightening, the procedure is safe and
painless. For some people, ECT is safer than anti-depressant
medication. The choice of treatment will always be up to the
woman.
Another life-threatening
complication of depression is suicide. Most of us find life a
burden during the most difficult moments of our lives, but
we're able to remember the things we live for and to go on.
When a woman starts to lose that ability and thinks or talks
seriously about harming herself, she must be taken seriously.
Suicide attempts are more common in women than in men, though
more men actually "succeed" in killing themselves.
Women tend to turn to methods that are less violent and that
therefore offer more chance of recovery. Suicide is a
tragically common cause of death among adolescents and the
elderly as well.
A woman who may be suicidal must
not be left alone, even for a moment. Help may be obtained
from a suicide hotline listed in the telephone directory, from
the police, or at a hospital emergency room. It's better to be
safe than sorry.
Some people make repeated suicide
attempts. People who know them may be tempted to downplay
their subsequent threats of suicide, but this is a mistake.
The likelihood of killing oneself is actually increased when
there have been previous attempts.
GETTING THE MOST FROM TREATMENT
At your first visit, your physician
or therapist will probably ask about symptoms, your general
health, and whether anyone in your family has had a mental
disorder. Your family's medical history is important, too. A
physical examination and laboratory tests are often done to
look for any physical problems that could be causing the
depression.
Give your doctor or therapist as
much information as you can about your health and mental
state. Be honest and open. To get the most out of treatment,
keep all appointments, ask as many questions as you want, take
your medications as prescribed, report any side effects, and
tell your therapist how well the treatment is working.
In addition, many people find it
useful to chart their progress. In a calendar or diary, they
record the medications taken that day, any side effects
experienced, physical and mental symptoms, and any activity
related to therapy, such as a visit to the therapist or
"homework" assigned for therapy. Such homework might
include an assignment to spend an hour socializing.
If you haven't found treatment
helpful after a month or two, ask your therapist whether
another kind of therapy might be more beneficial. A change in
the type or amount of medication you're taking may be called
for. If symptoms of depression return after treatment ends,
contact your physician immediately.
SETTING GOALS FOR PSYCHOTHERAPY
Therapy usually requires 20 visits
or less, although it can be continued longer if it remains
helpful. It's useful, however, to set goals for therapy, with
specific time limits. For example, if you aren't feeling any
better after 6 weeks, or completely better after 12 weeks, ask
the counselor about other treatments or call your physician.
You may want to start again with a different therapist.
You're much more likely to complete
a course of therapy if you're comfortable with your counselor.
If rapport could stand improvement, discuss the matter with
the therapist or try another counselor.
Long-term therapy to prevent future
depression is usually not recommended unless the patient is
pregnant or medications have produced unacceptable side
effects. While talk therapy won't prevent another episode of
depression, it may delay a recurrence.
Before you see a counselor, read
your health insurance policy carefully. Most insurers limit
the number of counseling sessions allowed. Feel free to
discuss cost with the therapist before you embark on a course
of therapy. Payment may be available on a sliding scale or
even free at some clinics. If you are employed, your employer
is required under the Americans with Disabilities Act to make
"a reasonable accommodation" to your illness.
Scheduling changes at work may be necessary, for example.
Above all, if you think you may be
depressed, don't face it alone. If someone you care about
seems depressed, share what you have learned from this article
and guide the person in looking for help.
TAKING THE FIRST STEP
Seeing a health-care professional
who can treat depression is the first step to a cure. You may
decide to start with your personal physician. Health
professionals in various fields are trained and experienced in
treating depression.
Psychiatrists are physicians (MDs)
who specialize in mental disorders. Among the professionals
listed here, only they can prescribe drugs in all
jurisdictions. With the others, prescriptions can be obtained
from the family doctor while talk therapy continues with the
non-MD counselor.
Psychologists who do counseling for
depression have a doctoral degree or a master's degree in
counseling or psychotherapy.
Social Workers often have
specialized training in counseling.
Several national organizations will
provide the names of health-care providers on request as well
as free information (see "Information Sources").
Treatment or referrals may also be available from local
physicians, hospitals, and clinics; local health departments;
community mental health clinics; suicide hotlines; and
university medical centers.
Listed below are some commonly
mistaken beliefs about depression that keep many people from
seeking proper treatment, according to a recent survey by the
National Institute of Mental Health.
MYTH:
Depression is a sign of personal weakness or poor parenting.
FACT:
Nearly three-fourths of Americans (71%) said they thought
mental illness, including depression, is caused by emotional
weakness. Over two-thirds believed poor parenting was to
blame, and nearly half accused the mentally ill of bringing on
their own illness. Wrong. Depression is often caused by a
chemical imbalance in the brain. It is not the fault of the
patient, her emotions, or her parents.
MYTH:
Depression can't be cured.
FACT:
About half of Americans think that mental illness, including
depression, can't be cured. Not so. Depression can almost
always be overcome with medication, psychotherapy, or both.
One reason depression-induced suicide is so tragic is that it
could probably have been prevented with treatment.
MYTH:
Depression is a normal part of grieving.
FACT:
Grief is an appropriate response to the loss of a loved one.
Depression often appears for no apparent reason and nearly
always includes a feeling of worthlessness. Grief over the
loss of a loved one should begin to lessen within about six
months. Depression can continue for years.
MYTH:
Anxiety and depression are the same thing.
FACT:
Anxiety makes a person worry nearly all the time. Other
symptoms are inability to sleep, irritability, and a general
stressed-out feeling. With depression, the main feelings are a
generalized sadness and lack of energy, which aren't common
with garden-variety anxiety.
MYTH:
My depression will go away by itself if I just ride it out.
FACT:
An episode of depression may or may not go away on its own.
The first step should be to see a health-care professional in
case the depression can be traced to a physical problem and to
prevent an episode from becoming life-threatening.
Highly effective drugs have helped
relieve depression for millions of Americans. If the first
antidepressant prescribed for you works well, that's
wonderful-and that's true for one-half to two-thirds of people
who take medications for depression. For the rest, success
requires patience and persistence. All antidepressants require
2 to 3 weeks to take effect. Finding the medication that not
only works best but also produces the fewest disturbing side
effects - many of which last only a few days - can take
several tries.
Three main classes of
antidepressants are used:
CYCLICS, which are older
medications with a longer track record.
SELECTIVE SEROTONIN REUPTAKE
INHIBITORS (SSRIs) and serotonin and norepinephrine reuptake
inhibitors (SNRIs), which are newer and generally more
expensive medications with fewer side effects than cyclics.
MONOAMINE OXIDASE INHIBITORS (MAOIs),
which are also older medications that require strict dietary
restrictions when being taken.
The first antidepressant prescribed is usually a cyclic, SSRI, or SNRI medication. Other drugs called mood stabilizers, including lithium, are used to treat manic depression.
The entire staff of Associated Counselors & Therapists has extensive experience treating Depression.
For More information, visit: http://www.depression.realage.com/
