by Elyse M. Rogers
A few weeks ago I heard a man named Jim speak about his personal experience with clinical depression. Jim has just retired from an executive position with a large, international firm, but he spoke about a time during his early 40’s when he’d been terribly depressed— so depressed that he’d had to take a six-month leave of absence from his job because he simply could not function.
He lost interest in his family and friends (although he was fortunate in that his family did hang in there with thim—often families do not), had terrible insomnia and several times even planned suicide although he never actually attempted it.
Fortunately, Jim was eventually diagnosed as having a bipolar depressive disorder (sometimes called manic depressive disorder). With medication (lithium carbonate) and help from a support group, Jim gradually came out of his depression and was able to function normally. He is very active in the U.S. National Depressive and Manic Depressive Association (NDMDA) at both the national and local levels.
Clinical depression is unfortunately not something that just affects Jim or a few others. In the United States alone it’s estimated that between 13 and 20 percent of the population (or about 10 million Americans) have some depressive systems at any given time.
The estimated financial impact of such disorders in the U.S. is $16 billion annually, with about $10 billion of that from lost productivity. Specific statistics about Japan are difficult to come by, but most physicians here admit that clinical depression is on the rise.
Since one of the major difficulties with people who are depressed is that they are often misdiagnosed, by learning about depression we may be able to help a friend or loved one who is suffering now or might suffer in the future from this problem.
DEPRESSION OR ‘THE BLUES’
None of us go through life without ever feeling “down. That’s normal. Clinical depression is something else again, mainly having to do with the depth and duration of the depression. Before 1980, diagnosing depressive disorders was not easy even for physicians, and often was kind of a hit-or-miss situation.
However, in that year a book entitled The Diagnostic and Statistical Manual of Mental Disorders was published by the American Psychiatric Association. The book includes a system for classifying mental and emotional disorders that is still widely used today.
According to that book, five of the following nine symptoms must be present most of the day, nearly every day, during a two-week period before a person can be diagnosed as having clinical depression. Let me list those nine important early warning signs. (Note: the first two are considered the most important, and one of the two must be present for a positive diagnosis.)
1) Depressed mood or pervasive feelings of sadness, helplessness and hopelessness.
2) Loss of interest or pleasure in usual activities.
3) Significant change of appetite or weight loss or gain (more than 5 percent of normal body weight) when not dieting.
4) Disturbances in sleep patterns, whether insomnia (difficulty falling asleep, early morning awakening, or waking in the middle of the night), or hypersomnia (excessive sleepiness). (Can’t resist asking how you like that scientific word for excessive sleepiness. Now instead of admitting you’re a couch potato when you sleep till noon on weekends, you can tell your associates you suffer from a condition called hypersomnia!)
5) Agitation or a generalized slowing of intentional bodily activity known as psychomotor retardation (such as stooped posture or monotonous, slow speech)
6) Fatigue or loss of energy.
7) Feelings of worthlessness or excessive or inappropriate guilt.
8) Inability to concentrate or think; indectsiveness.
9) Recurrent thoughts of death or suicide, or a suicide attempt.
Depressive disorders occur most often between ages 25 and 44, although major depression has been documented in very young children and the aged. Women (another bad break for us females) arc twice as likely to be struck by depression as men.
DEPRESSION AND PHYSICAL COMPLAINTS
Most of us look to our family physician when we have a problem, and clinically depressed patients tend to do jus that. However, they are often misdiagnosed for a couple of reasons: patients tend to report the physical symptoms of depression such as headache, fatigue and insomnia rather than on the mental; and family doctors are oriented towards laboratory tests or other tests designed to uncover physical illnesses. As a result the patient is often told “there’s nothing wrong with you” or worse, is labeled by his physician and family as a hypochondriac.
Since there is as yet no genetic or laboratory test for depression, a correct diagnosis depends on the doctor’s accurate assessment of the patient’s mood, symptoms and functioning.
TYPES OF DEPRESSION
There are two kinds of clinical depression or major depression:
• Unipolar depression is the most common, (occurring in two-thirds to three-fourths of the cases) and is a severe, chronic depression (with no “highs” involved). It is called “unipolar” since the one “pole” or problem is depression.
Typically the patient exhibits all those symptoms we tend to associate with depression: pessimism, disturbed sleep and appetite patterns, impaired sensory and sexual pleasures, fatigue and possibly suicidal tendencies.
• Bipolar depression is a condition where patients experience recurrent cycles of both depression and mania (high elation), or two “poles.” The mania phase shows itself with behavior of very high energy, high self-esteem, rapid speech, decreased need for sleep and grandiose ideas. During the manic phase, patients often have bizarre social behavior and may make poor decisions about important matters (such as investing money).
During the depressed phase, patients exhibit symptoms similar to those of unipolar disorder victims.
THE CAUSES OR THEORIES ABOUT CAUSES
Scientists have learned a good deal more about depression today, but still, there’s lots unknown. Particularly, scientists do not know the exact mechanism that triggers depressive illnesses. It’s thought that multiple causes are probable, including those listed below:
1) Heredity. In 1987, a major discovery in bipolar disorders indicated that there is a genetic transmission of the illness within families. Researchers are continuing to get more information on the new “genetic marker” that was traced to Chromosome 11; most feel that in the future more than one gene will most likely he identified for depressive illnesses.
2) Environment. Significant stress such as loss of a loved one or job loss can bring on depression in some cases.
3) Background and personality. Certain personalities tend to be more vulnerable to depression, and some cases can be linked to troubled childhood, bad parent/child relationships, etc.
4) Biochemical factors. Abnormal chemical activity in the brain may be a factor, particularly regarding the neurotransmitters (chemical messengers) which have to do with the complex interactions that control moods. Three neurotransmitters have been associated with depressive conditions: dopamine, norepinephrine and serotonin.
TREATMENT OF DEPRESSION
There are three common treatments for depression, with the goal being to reduce symptoms, improve function and prevent suicide.
• Electroconvulsive therapy (ECT). For years this was the treatment of choice and it was called “electric shock therapy.” This is (and was) a very fine treatment that got a lot of bad press (in my view) and became very controversial. True, it wasn’t very sophisticated, and although ECT did not actually cause pain in itself, some patients had severe apprehension before the treatment.
Happily, today this treatment is much more sophisticated and humane (sedation is provided prior to treatment), and is coming back into use for patients who need quick and reliable treatment, or for those who cannot tolerate antidepressant medications.
• Antidepressant medications. Certainly antidepressant medications have been almost a miracle drug for those with depressive illnesses (and other mental illnesses) allowing patients to function within their normal environment or to progress to that point. Normally it takes antidepressants about 10-20 days to become fully effective.
There are three major types of antidepressants —- tricyclics, MAO inhibitors and lithium. I mentioned lithium carbonate before, and it is mainly used for people with manic-depressive (bipolar) illness. Tricyclics are more commonly prescribed for unipolar conditions where people have the classic symptoms of depression; MAO inhibitors that prevent the body’s breakdown of certain neurotransmitters) are used mostly for sufferers who have atypical unipolar depression with symptoms such as hypersomnia (remember? too much sleep), and excessive weight gain.
As with any medications the antidepressants can have side effects, so patients taking them should be monitored during treatment. Fortunately, some of the newer drugs have fewer side effects.
• Psychotherapy. “Talk therapy” is a better name for psychotherapy, I think, since many seem to think of psychotherapy (although that is part of it too). Short-term psychotherapy has become increasingly popular since 1986 when research results showed that this type of therapy was as effective as medication for depressed patients. In most programs of treatment, medication and psychotherapy are combined for best results.
The two most widely used short term psychotherapy programs arc interpersonal psychotherapy and cognitive/behavioral therapy. In interpersonal psychotherapy the therapist helps the patient understand his/her illness and how depression and interpersonal conflicts are related; in cognitive/behavior therapy, therapists use various techniques to help patients get rid of their negative thought patterns and beliefs and thereby control (heir emotions in a more positive way.
We’re fortunate in Tokyo there are several fine private counseling professionals as well as two non-profit counseling organizations who can help those fighting depression. Tokyo Community Counseling Service has professional counselors to serve the foreign community (phone 780-0336); Tokyo English Life Line (TELL) is more of an emergency and referral organization, although they have trained phone counselors (phone 264-4347).