Depression

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Depression

One of the most common modern emotional complaints, depression is sometimes referred to as "the common cold of psychiatric illness." In its everyday usage, the word "depression" describes a feeling of sadness and hopelessness, a down-in-the-dumps mood that may or may not be directly attributed to an external cause and usually lasts for weeks or months. Sometimes it is used casually ("That was a depressing movie") and sometimes it is far more serious ("I was depressed for six months after I got fired"). Though depression has been recognized as an ailment for hundreds of years, the numbers of people experiencing symptoms of depression has been steadily on the rise since the beginning of the twentieth century.

The cause of depression is a controversial topic. Current psychiatric thinking treats depression as an organic disease caused by chemical imbalance in the brain, while many social analysts argue that the roots of depression can be found in psychosocial stress. They blame the increasing incidence of depression on an industrial and technological society that has become more and more isolating and alienating as support systems in communities and extended families break down. Though some depression seems to descend with no explanation, more often depression is triggered by trauma, stress, or a major loss, such as a relationship, job or home. Many famous artists, writers, composers, and historical figures have reportedly suffered from depressive disorders, and images and descriptions of depression abound in literature and art.

In its clinical usage, "depression" refers to several distinct but related mental conditions that psychiatrists and psychologists classify as mood disorders. Although the stresses of modern life may leave a great many people with feelings of sadness and hopelessness, psychiatrists and psychologists make careful distinctions between episodes of "feeling blue" and "clinical depression." According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), an episode of depression is not a "disorder" in itself, but rather a "building block" clinicians use in making a diagnosis. For example, psychiatrists might diagnose a person suffering from a depressive episode with substance-induced depression, a general medical condition, a major depression, chronic mild depression (dysthymia), or a bipolar disorder (formerly called manic depression).

Psychiatrists attribute specific symptoms to "major depression," which is diagnosed if a client experiences at least five of them for at least two weeks. In addition to the familiar sad feeling, the symptoms of major depression include: diminished interest and pleasure in sex and other formerly enjoyable activities; significant changes in appetite and weight; sleep disturbances; agitation or lethargy; fatigue; feelings of worthlessness and guilt; difficulty concentrating; and thoughts of death and/or suicide.

Although people of all ages and backgrounds are diagnosed with major depression, age and culture can affect the way they experience and express their symptoms. Children who suffer from depression often display physical complaints, irritability, and social withdrawal, rather than expressing sadness, a depressed mood, or tearfulness. While they may not complain of difficulty concentrating, such difficulties may be inferred from their school performance. Depressed children may not lose weight but may fail to make expected weight gains, and they are more likely to exhibit mental and physical agitation than lethargy.

Members of different ethnic groups may also describe their depressions differently: complaints of "nerves" and headaches are common in Latino and Mediterranean cultures; weakness, tiredness, or "imbalance" are more prevalent among Asians; and Middle Easterners may express problems of the "heart." Many non-western cultures are likely to manifest depression with physical rather than emotional symptoms. However, certain commonalities prevail, such as a fundamental change of mood and a lack of enjoyment of life. Many studies have shown that cross-national prevalence rates of depression seem to be at least partially the result of differing levels of stress. For example, in Beirut, where a state of war has existed since the 1980s, nineteen out of one hundred citizens complained of depression, as compared to five out of one hundred in the United States.

One thing that does appear to be true across lines of culture and nationality is that women are much more likely than men to experience depression. The DSM-IV reports that women have a 10-25 percent lifetime risk for major depression, whereas men's lifetime risk is 5-12 percent. Some theorists argue that this difference may represent an increased organic propensity for depressive disorders, or may be due to gender differences in help-seeking behaviors, as well as clinicians' biases in diagnosis. Feminists, however, have long linked women's depression to social causes. Poverty, violence against women, and lifelong discrimination, they contend, offer ample triggers for depression, especially when coupled with women's socialized tendency to internalize the pain of difficult situations. Whereas men are socialized to express their anger outwardly and are more likely to be diagnosed with antisocial personality disorder, women are far more likely to entertain feelings of guilt and thoughts of suicide. Interestingly, there is evidence that in matriarchal societies, such as Papua New Guinea, the statistics of male and female depression are reversed.

Manic depression or bipolar disorder is the type of depression which has received the most publicity. The theatrical juxtaposition of the flamboyant manic state and incapacitating depression has captured the public imagination and been the inspiration for colorful characters in print and film from Sherlock Holmes to Holly Golightly. Clinicians diagnose a bipolar disorder when a person experiences a manic episode, whether or not there is any history of depression. The DSM-IV defines a manic episode as "a distinct period of abnormally and persistently elevated, expansive or irritable mood that lasts at least one week," and is characterized by: inflated self-esteem or grandiosity; decreased need for sleep; excessive speech; racing thoughts; distractibility; increased goal-directed activity and/or agitation; and excessive pleasure-seeking and risk-taking behaviors (the perfect personality for a dramatic hero). Bipolar disorders are categorized according to the type and severity of the manic episodes, and the pattern of alteration between mania and depression.

Depression is not only an unpleasant experience to live through, it is often fatal. Up to 15 percent of those with severe depression commit suicide, and many more are at risk for substance abuse and other self-destructive behavior. It is no wonder that doctors have tried for centuries to treat those who suffer from depression. Aaron Beck, author of Depression: Clinical, Experimental, and Theoretical Aspects, credits Hippocrates with the first clinical description of melancholia in the fourth century B.C.E. and notes that Aretaeus and Plutarch—both physicians in the second century C.E.—described conditions that would today be called manic-depressive or bipolar disorders. Beginning in antiquity, melancholia was attributed to the influence of the planet Saturn, and until the end of the seventeenth century, depression was believed to be caused by an accumulation of black bile, resulting in an imbalance in the four fluid components of the body. Doctors of the time used purgatives and blood-letting to treat depression. Despite changes in the nomenclature and the attribution of causes for melancholia, contemporary psychiatric criteria for major depression and the bipolar disorders are strikingly consistent with the ancient accounts of melancholia.

In the nineteenth century, melancholia was similarly described by such clinicians as Pinel, Charcot, and Freud. In his essay "Mourning and Melancholia," written in the 1930s, Sigmund Freud distinguished melancholia from mourning—the suffering engendered by the loss of a loved one. In melancholia, Freud argued, the sufferer is experiencing a perceived loss of (a part of) the self—a narcissistic injury that results in heightened self-criticism, self-reproach, and guilt, as well as a withdrawal from the world, and an inability to find comfort or pleasure. Freud's psychoanalytic interpretation of melancholia reflected a shift from away from biological explanations.

Following Freud, clinicians ascribed primarily psychological causes—such as unresolved mourning, inadequate parenting, or other losses—to the development of depression, and prescribed psychotherapy to seek out and resolve these causes. Today, the pendulum has swung back to include the biological in the understanding of depressive disorders. While most contemporary clinicians consider psychological causes to be significant in triggering the onset of depressive episodes, research has indicated that genetics play a significant role in the propensity toward clinical depression. In the 1960s and 1970s radical therapy movements, along with feminism and other social movements, began to question the entirely personal interpretation placed on depression by many psychiatrists and psychologists. These activists began to look to society for both the cause and the cure of depression and to question therapy itself as merely teaching patients to cope with unacceptable societal situations.

Along with "talking therapy," science continues to search for a medical cure. In the 1930s, Italian psychiatrists Ugo Cerletti and Lucio Bini began to experiment with electricity to treat their patients. Electroconvulsive shock therapy (ECT) became a standard treatment for schizophrenia and depression. ECT lost favor in the 1960s when many doctors and anti-psychiatry activists, who considered it as barbaric and dangerous as leeches, lobbied against its use. Shock therapy was often a painful and frightening experience, sometimes used as a punishment for recalcitrant patients. Public feeling against it was aroused with the help of books such as Ken Kesey's One Flew Over the Cuckoo's Nest in 1963, actress Frances Farmer's 1972 autobiography Will There Really be a Morning?, and Janet Frame's Angel at My Table in 1984. Perhaps as a testimony to the inherent drama of depression and its treatment by ECT, each of these books were made into films: One Flew Over a Cuckoo's Nest (1975), Frances (1982), and Angel at My Table (1990). ECT made a comeback in the 1990s, when proponents claimed that improved techniques made it a safe, effective therapy for the severely depressed patient. Side effects of ECT still include loss of memory and other brain functions, however, and in 1999, Italy, its birthplace, severely restricted the use of ECT.

Many medications have been developed in the fight against depression. The tricyclics—which include imipramine, desipramine, amitriptyline, nortriptyline, and doxepin—have been found to be effective in controlling classic, melancholic depression, but are known for triggering side effects associated with the "flight or fight" response: rapid heart rate, sweating, dry mouth, constipation, and urinary retention. Another class of antidepressant medication, the monoamine oxidase inhibitors (MAOIs) have been more effective in alleviating the "non-classical" depressions that aren't helped by tricyclics. Although the MAOIs—phenelzine, isocarboxazid, nialamide, and tranylcypromine—are more specific in their action, they are also more problematic, due to their potentially fatal interactions with some other drugs, alcohol, tricyclic antidepressants, anesthetics, and foods containing tyramine. The most dramatic and widely publicized development in the psychopharmacological treatment of both major depression and chronic mild depression has been the availability of a new class of antidepressant medication, the selective serotonin reuptake inhibitors (SSRIs). SSRIs increase brain levels of serotonin, a neurotransmitter linked to mood. These medications—which include Prozac, Paxil, and Zoloft—are highly effective for many people in alleviating the symptoms of major depression, and have had a surprising success in lifting chronic depressions as well. They are touted as having far fewer adverse effects than drugs previously used to treat depression, which has contributed to their enormous popularity. However, they do have some serious side effects. These include reduced sexual drive or difficulty in having orgasms, panic attacks, aggressive behavior, and potentially dangerous allergic reactions. Prozac, probably one the most widely advertised medicinal brand names in history, has also had considerable exposure on television talk shows and other popular media, and has become the antidepressant of the masses. By 1997, just ten years after it was placed on the market, twenty-four million people were taking Prozac in almost one hundred countries. While most of these were grasping at the appealing notion of a pill to make them feel happier, Prozac is also prescribed in a wide variety of other cases, from aiding in weight loss to controlling adolescent hyperactivity.

In general, psychiatrists do not prescribe antidepressant medications in the treatment of bipolar disorders, because of the likelihood of triggering a manic episode. Rather, extreme bipolar disorders are treated with a mood stabilizer, such as Lithium. Lithium is a mineral, which is found naturally in the body in trace amounts. In larger amounts it can be toxic, so dosages must be closely monitored so that patients do not develop lithium toxicity. Lithium has received much popular publicity as a dramatic "cure" for manic-depression, notably in television and film star Patty Duke's autobiography, Call Me Anna (1987), where Duke recounts her own struggles with violent mood swings. Other, more extreme, drugs also continue to be prescribed to fight depression. These are the anti-psychotics, also called neuroleptics or even neurotoxins. These drugs, such as Thorazine, Mellaril, or Haldol—may be used to alleviate the psychotic symptoms during a major depressive episode. The neuroleptics can have extremely harsh adverse effects, from Parkinson's disease to general immobility, and are sometimes referred to as "pharmacological lobotomy." The stereotypical movie mental patient with glazed eyes and shuffling gait is derived from the effects of drugs like Thorazine, which are often used to subdue active patients.

In 1997, antidepressants represented an almost $7 billion a year industry. Though safer and more widely available antidepressant medication has clearly been a breakthrough for many of those who suffer from debilitating depression, three out of ten depression sufferers don't respond at all to a given antidepressant, and of the seven who respond, many do so only partially or find that the benefits "wear out." Some therapists and other activists worry about the implications of the "chemical solution," claiming that antidepressants are over-prescribed. For one thing, all of the drugs have worrisome adverse effects, which are often downplayed in manufacturers' enthusiastic advertisements. For another, there has been successful research into using antidepressants to help victims of rape, war, and other traumatic stress. In a study at Atlanta's Emory University, four out of five rape victims became less depressed after a twelve-week program of the SSRI Zoloft. While some greet this as a positive development, others are chilled at the prospect of giving victims pills to combat their natural reactions to such an obvious social ill. Most responsible psychologists continue to see the solution to depression as a combination of drug therapy with "talking therapy" to explore a client's emotional reactions.

Many famous artists and historical figures have reportedly suffered from depression (melancholia) or bipolar disorder (manic depression). Aristotle wrote that many great thinkers of antiquity were afflicted by "melancholia," including Plato and Socrates, and cultural historians have included such names as Michaelangelo, Danté, Mary Wollstonecraft, John Donne, Charles Baudelaire, Samuel Coleridge, Vincent Van Gogh, Robert Schumann, Hector Berlioz, Virginia Woolf, Sylvia Plath, and Anne Sexton among their lists of melancholic artists, writers and composers.

Depression has also been described in literary texts throughout history. In his seminal essay "Mourning and Melancholia," Freud referred to Shakespeare's Hamlet as the archetype of the melancholic sufferer, and Moliere's "Misanthrope" was "atrabilious," a term denoting the "black bile" that medieval medicine considered to be the cause of melancholia. Descriptions of characters suffering from depression can also be found in Flaubert's Madame Bovary and Kafka's Metamorphosis. The poetry of Edna St. Vincent Millay presents a depressed cynicism that is the result perhaps of both personal loss and the wider cultural loss of disillusion and war. And of course, Sylvia Plath's The Bell Jar (1963) is one of the most finely crafted modern portraits of the depressed heroine, "the perfect set-up for a neurotic… wanting two mutually exclusive things at the same time." In recent years, perhaps in response to the increasing discussion of depression, a new genre has appeared, the memoir of depression. Darkness Visible (1990) by William Styron, Prozac Nation: Young and Depressed in America (1995) by Elizabeth Wurtzel, and An Unquiet Mind by Kay R. Jamison (1995) are examples of this genre, where the author explores her/his own bleak moods, their causes, their effects on living life, and—hopefully—their remedy.

Whether one defines depression as a biological tendency that is activated by personal experience or as a personal experience that is activated by socio-political realities, it is clear that depression has long been a significant part of human experience. Coping with the complexities and contradictions of life has always been an overwhelming prospect; as society becomes more complex, the job of living becomes even more staggering. In words that still ring true, Virginia Woolf, who ended her own recurrent depressions with suicide at age 59, described this feeling: