Depression: Symptoms and Treatment
In western Nigeria, an energetic Yoruba woman gradually withdraws from village life, ceases tending her garden, and ? to the dismay of her family and neighbors ? spends her days staring at the wall of her hut. In Osaka Japan, a conscientious college student suffers weeks of anxiety and shame, convinced he will fail an upcoming examination, and prepares to disembowel himself. In Southern California, a hard-driving sales manager repeatedly cancels important appointments, lets his paper work pile up and indulges in cocktails until past midnight.
These three individuals could hardly be more unlike in cultural experience, social background and way of life. Emotionally, however, the disconsolate African mother, the suicidal Japanese youth and the procrastinating American businessman resemble one another more closely than they do their own family.
Almost everyone suffers periods of depression, the reaction to some shattering event ? the loss of a job, serious bodily injury, the death of a loved one - the despair can be so black that treatment is called for; however, in millions of people depression occurs for no apparent reason.
Mood disorders can range from mild to severe and can linger for many months or even years. Mood disorders are divided into depressive disorders, in which the individual has one or more periods of depression without a history of manic episodes, and bipolar disorders, in which the individual alternates between periods of depression and periods of elation, usually with a return to normal mood in between the two extremes; however, manic episodes without some history of depression are very uncommon. Negative feelings dominate aspects of living and , in some cases, can lead to hallucinations, withdrawal from all activities, and complete breakdown, physical as well as mental. Such depressions constitute a debilitation sickness that, according to
American psychiatrist Hugh Storrow, "probably causes more human suffering than any other single disease ? mental or physical" (Campbell).
It is sometimes referred to as the common cold of mental illness, but it is the prime cause of admission to mental hospitals in Britain and ranks second only to schizophrenia in filling mental wards in the United States. The World Health Organization estimates that one of every five persons in the technically advanced countries experience depression, and it is rapidly on the rise in underdeveloped countries. Depression paves the way for drug abuse, especially of amphetamines and other drugs that induce excitement ? a "high" to counteract the low of depression. It is a precursor to alcoholism for millions of people, and because seventy-five per cent of all suicide attempts are attributable to depression, it is, in Storrow's words, "one of the few psychiatric illnesses with a significant mortality rate" (Campbell). Depression is an illness, in the same way that diabetes or heart disease are illnesses. It affects the entire body, not just the mind, and one in five people will suffer from it in their lifetime. Untreated depression is the number one cause of suicide and it is second only to heart disease in causing lost workdays in America.
Depression is no respecter of persons. It affects the rich, poor, young, and old alike. It is mentioned as far back as the Bible, when Job lamented: "Why didst thou bring me forth from the womb? Would that I had died before any eye had seen me... Where then is my hope?" (Bible). Abraham Lincoln endured such low periods that he suspected he might kill himself during one of these sieges, so he would not even carry a pocketknife (Campbell). Hippocrates (the father of medicine), Winston Churchill, Nathaniel Hawthorne, Edgar Allen Poe, Sylvia Plath, Virginia Woolf, Colonel Edwin E. "Buzz"
Aldrin Jr. (the second man to walk on the moon), and even Sigmund Freud were sufferers ? along with millions more ? of depression
Although depression can happen to anyone, various studies suggest that it occur more often in women than in men and more often in married than in single people. One estimate indicates that three times as many women as men experience depression, but no one is sure why. Some experts speculate that hormonal differences may be to blame, but others authorities challenge the estimate itself. Myrna Weissman, professor of psychiatry at Yale University, noted that men are generally more reluctant to acknowledge depression and are more likely to mask it with alcohol. Statistics seem to reinforce this view; the alcoholism rate is four times higher among men than women.
Recognizing depression poses a challenge, not only because it takes various forms but also because certain symptoms ? crying jags, sleeplessness, or loss of appetite ? can apply with equal validity to mild, neurotic depressions that impair some of an individual's capacities and to severe psychotic depressions. Although depression characterized as a disorder of mood, there are actually four sets of symptoms. In addition to emotional (mood) symptoms, there are cognitive, motivational, and physical symptoms. An individual does not have to have all of these to be diagnosed as depressed, but the more symptoms he has, and the more intense they are, the more certain we can be that the individual is suffering from depression.
The American Psychiatric Association's guidelines distinguish between two basic types of depressive disorders: those that are affective, or endogenous, that is, internally caused, not brought on by an external incident; and those that are reactive, responses to some overt stress situation. Generally speaking, endogenous depression is more severe and longer lasting, and it is psychotic ? the patient is so deeply disturbed he
loses contact with reality. In reactive depression, the victim understands the reasons for his sadness and remains rational; also, it usually has a relatively short time frame, usually ending when there is an improvement in the stress situation that brought it on.
A common type of mood disorder is a bipolar disorder in which individuals are excessively and inappropriately happy or unhappy. These reactions may take the form of high elation, hopeless depression, or an alternation between the two.
In a manic-type reaction, a person experiences elation, extreme confusion, distractibility, and racing thoughts. Often, the person has an exaggerated sense of self-esteem and engages in irresponsible behavior such as shopping sprees or insulting remarks. In some cases the cycle between depressive episodes and manic episodes is swift with only a brief return to normality in between. This state is not as easy to detect as some others because the person is optimistic, seeming to be in touch with reality, and blessed with an unending sense of optimism. During a manic episode, a person may behave as if he or she needs less sleep, and the activity level typically increases, as does the loudness and frequency with which he speaks. People experiencing manic episodes behave in a way that appears, on the surface, to be the opposite of depression. During mild manic episodes, the individual is energetic, and full of self-confidence. He talks continually, rushes from one activity to another with little need of sleep, and makes grandiose plans, paying little attention to their practicality. Unlike the kind of joyful exuberance that characterizes normal elation, manic behavior has a driven quality and often expresses hostility more than it does elation. They are angered by attempts to interfere with their activities and may become abusive. Impulses (including sexual ones) are immediately expressed in actions or words. These individuals are confused and disoriented and may experience delusions of great wealth, accomplishment, or power.
In the depressive-type reaction, the individual is overcome by feelings of failure, sinfulness, worthlessness, and despair. In contrast to the optimism and high activity of a manic-type reaction, lethargy, despair, and unresponsiveness mark a depressive-type reaction. The behavior of someone with a major depressive disorder is essentially the same as someone who is depressed in a bipolar disorder (Perris, 1982). In some cases, a patient will alternate between frantic action and motionless despair. Some people experience occasional episodes of a manic type or depressive type reaction, separated by long intervals of relatively normal behavior. Other exhibits almost no normal behavior, cycling instead from periods of manic-type reactions to equally intense depressive type reactions.
Manic episodes can occur without depression, but this is very rare. Usually a depressive episode will occur eventually, once a person has experienced a manic episode.
Bipolar disorders are relatively rare. Whereas about 6 percent of adult females and 3 percent of adult males in the United States have experienced a major depression at some time, less than 1 percent of the adult population has had a bipolar disorder, which appears to be equally common in men and women. Manic-depression differs from other mood disorders in that it tends to occur at an earlier age, is more likely to run in families, responds to different therapeutic medications, and is apt to recur unless treated. These facts suggest that biological variables play a more important role than psychological variables in bipolar disorders. Feeling unusually "high," euphoric, or irritable; needing less sleep; talking a lot or feeling that you can't stop talking; being easily distracted; having lost of ideas go through your head very quickly at one time; doing things that feel good but have bad effects (spending too much money, excessive sexual activity, foolish business investments); having feelings of greatness; or making lots of plans for activities
(at work, school, socially, or sexually) or feeling that you have to keep moving are some of the symptoms of bipolar disorder, and if a person has four of these symptoms at one time for at least one week, they may have had a manic episode.
However important the cause of a depression may be, it does not matter much in the first step of treatment: recognizing that the problem exists. Though this seems obvious, refusal to acknowledge a depressed state is common. In mild or moderate depressions, the victim ? and people around him ? may pass off a serious attack as a temporary siege of the blues. Even when the condition is chronic, one survey has shown, as long as two to five years may elapse before the sufferer will seek professional help.
Once people become depressed and inactive, their mail source of reinforcement is the sympathy and attention they receive form relatives and friends. The attention may initially reinforce the very behaviors that are maladaptive. Because it is tiresome to be around someone who refuses to cheer up, the depressed person's behavior eventually alienates even close associates, producing a further reduction in reinforcement and increasing the individual's social isolation and unhappiness.
People who have major depressive disorder have a number of symptoms nearly every day, all day, for at least two weeks. These always include at least one of the following: loss of interest in things; feeling sad, blue, or down in the dumps; feeling slowed down or restless and unable to sit still; feeling worthless or guilty; increase or decrease in appetite or weight; thoughts of death or suicide; problems concentrating, thinking, remembering, or making decisions; trouble sleeping or sleeping too much; and loss of energy or feeling tired all of the time. There are often other physical or psychological symptoms, including headaches, other aches and pains, digestive problems, sexual problems, feelings of pessimism or hopelessness, and being anxious or worried. However, sadness
and dejection are the most salient emotional symptoms in depression. The person feels hopeless and unhappy, often has crying spells, and may contemplate suicide. Equally pervasive in depression is the loss of gratification or pleasure in life. Activities that used to bring satisfaction seem dull and joyless., and the individual gradually loses interest in hobbies, recreation, and family activities.
Motivation is at low ebb in depression. The depressed person tends to be passive and has difficulty initiating activities. Since the depressed person's thought are focused inward, rather than toward external events, he may magnify aches and pains and worry about health.
Measuring the depth of a depression has been made easier with the development of a specific diagnostic tool ? a rating scale for depression. A patients rating is based solely upon his symptoms, either as voiced by him or as observed by a trained psychiatric worker.
One widely used rating scale for depression is by Aaron Beck. Beck based his work on the assumption that the "key factor in diagnosing depression is change in the psychobiological systems" ? change, in short, in the patient's physiology, behavior, emotions, motivations and view of himself. To measure the changes the inventory poses twenty-one sets of statements; in each set, the patient is asked to choose the statement most applicable to him at that moment. For example, among the cognitive changes that are looked for is a decline in the patient's estimate of his ability to make decisions. He is presented with four statements:
I make decisions about as well as ever.
I try to put off making decisions.
I have great difficulty in making decisions.
I can't make any decisions at all anymore.
Other sets examine such areas as the person's ability to sleep and work, suicidal thoughts, sexual drive and interest in other people. The more negative the response, the higher the overall score, and the more severe the depression.
The diagnosis of a patient's depressed state ? whether by rating scale, by the psychiatrist's own observation, or by both ? serves as the guideline to choice of treatment. However, whether the case is mild, moderate or severe, and whether the cause is known or unknown, most treatments concentrate on combining psychotherapy and antidepressant drugs.
Three classes of antidepressant medication in widespread use today are the so-called tricyclics, bicyclics, and the MAO ? for monoamine oxidase ? inhibitors. These increase the flow of chemical substances in the brain that are reduced or blocked in depressive states, and reduces the reabsorbation of serotonin or norepinephrine by the presynaptic neuron.. A third medication, used increasingly in cases of manic depression, is lithium, which affects the levels of sodium, potassium, magnesium and calcium in the body; it appears that if these vital minerals are not present in correct amounts depression may occur.
Once the medication has attacked the biochemical base of the depression, the therapist can begin to explore with the patient the emotional problems that contribute to the ailment. In severe cases, the therapy may initially consist of setting simple tasks for the patient in an attempt to alter the behavior that has become patterned during the illness.
Most people who are treated for depression feel better and return to daily activities in several weeks. Because it takes several weeks for treatment to work fully, it is important to get treatment early before the depression gets worse. As with any medical condition, one may have to try one or two treatments before finding the best one.
Therapy is used along with medication. In cognitive therapy, the therapist tries to replace negative beliefs thoughts with a three-step process: identify the negative beliefs that are influencing the patient's mood and behavior, testing to determine whether the hypotheses are valid, and finally, replacement of the erroneous negative beliefs with more accurate beliefs. If negative beliefs crop up again, the patient will have learned to check and eliminate them. The success of cognitive therapy depends on the patient's monitoring of thoughts so that he does not slip back into the habit of negative thinking. If they begin to slip, they are taught to ask three questions (Hollon & Beck, 1979):
What is my evidence for this belief?
Is there another way of looking at this situation?
Even if it is true, is it as bad as it seems?
Only about ten percent do not recover and remain chronically depressed (Lewinsohn, Fenn, & Franklin, 1982). Unfortunately, depressive episodes tend to recur. About half the individuals who have a depressive episode will experience another one.
Even for people who experience depression there is hope. Despite the profound suffering it causes, it is unlike many physical illnesses in that recovery is total. Depression does not leave the individual with a weakened heart, for example, or the partial loss of mobility. In fact, depression can help an individual to find a more satisfying and meaningful life. Frederic Flach, in a book entitled The Secret Strength of Depression, noted that many people rebound from depression better able to cope, often reaching new levels of creativity. The illness, he wrote, enables a person to examine, the relinquish, old assumptions that block a fresh appraisal of the possibilities in life. "to experience acute depression," Flach concluded, "is an opportunity for a person not just to learn more about himself, but to become more whole than he was" (Campbell 87).