Clinical Corner – What is 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:

1. A feeling of sadness, or periods of crying.

2. Feelings of guilt, self-blame, or worthlessness.

3. 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).

4. Changes in appetite and weight (adults usually lose; younger depressed patients may eat more and gain).

5. Decreased interest in sex.

6. Decreased ability to enjoy things one used to enjoy.

7. Decreased ability to concentrate.

8. Decreased energy.

9. Feelings of hopelessness and helplessness.

10. 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.

What Depression Isn't: Common Myths

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.

Medications To Treat Depression

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.