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.


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.


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.


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.


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.


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).