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Speaking to patients about depression is difficult because the word depression is used in different ways. One commonly speaks of being depressed when disappointed or frustrated. It is a universal feeling, immediately understood by everyone. Like joy, anger, longing and all the other named emotions, depression has been experienced by everyone. Used in this sense, depression is not abnormal. Although painful, It is an appropriate and inevitable response to circumstances. The feeling of depression will remit quickly if the circumstances of life change.
But there are conditions where the feeling of depression is part of a more prolonged disturbance of mind, which is manifested not just in sad feelings, but in certain typical thoughts and behavior. It is usually this intense state that impels someone to seek treatment. After an initial evaluation of depressed patients, I explain to them a little about different kinds of depression and why I think in their case I should prescribe medication—or not prescribe medication.
Before I report what I say to them, I must acknowledge that psychiatrists are not of one mind on this subject. For instance, anti-depressants are prescribed commonly (and I think, carelessly) in situations in which I would not. I will not presume to say that I am right, and they are wrong. There is little hard evidence about the way these drugs should be given. For instance, it was observed recently that many of the “scientific” studies that determined the value of these agents could not be replicated. On second look—long after these drugs were approved—some of these studies did not hold up. And yet, hundreds of millions of dollars were spent testing each of these drugs. Nevertheless, I think all psychiatrists, certainly including me, think these drugs do, in fact, work. But not all the time.
In appreciation of the fact that an initial course of an anti-depressant medication may not by itself cause a depression to remit completely, the American Psychiatric Association has produced an elaborate algorithm giving various choices of what to prescribe next. (Only about thirty to forty per cent of depressed patients respond within three weeks to a first anti-depressant, whichever anti-depressant is used.) Very briefly, the choices are to increase the dose of the first anti-depressant or add a second drug, and sometimes a third. That situation is remarkable in medicine because drugs found to augment the effect of antidepressants fall into four or five different classes: another anti-depressant, perhaps a tricyclic, an anti-psychotic, which is not used to counter a psychosis, but simply because it makes serotinergic agents like Prozac more effective, hormones, (thyroid) and a salt (lithium, used in smaller doses than it would be in bipolar disease.) Amphetamines, also, which are not a good treatment for depression given alone, have been used to augment the anti-depressant effects of other drugs. It is unusual, in my opinion, for treatment to fail in those depressions for which they are indicated. On the other hand, they will have only a placebo effect when given to other depressed individuals.
By the way, there are, perhaps, thirty anti-depressants in use—which is an indication that no one of them has been found to be obviously more effective than the others. They operate on different neurotransmitters—at least to a varying extent—but, nevertheless, all of them take at least three weeks to work no matter which class of anti-depressants they fall into. The particular drug the psychiatrist chooses is likely to depend on the potential side effects, which differ slightly from one drug to the next, on personal experience, and on what drugs are being promoted currently by one or another drug company.
With those caveats, this is us what I tell the depressed patients who find their way to my office:
“For purposes of talking about depression, I want to distinguish three different kinds of depression. Some people are always a little depressed. They have felt that way since they were young. They tend to have low self-esteem. They think they are not as attractive as they should be, or bright, or good in any other way. They do not perform as well as they should. They feel guilty in situations that others do not. They tend not to be assertive, because they do not think they deserve what others have; and they expect a bad result if they do reach out to others. That sort of depression reflects a point of view—about themselves and about the world. Such individuals may become pessimistic and bitter.
“These are learned attitudes, and, for the individual to give them up, they must be unlearned. The depression responds over a long period of time to psychotherapy and not to drugs. Maybe everyone has a little of this sort of depression.
“People can become profoundly depressed in the face of a serious loss—the death of someone very close, being abandoned or jilted by a lover, losing a valuable job and, sometimes, developing a serious illness. These are all losses of some sort. Someone who has been jilted, for example, can become so seriously depressed that that person may be considering suicide. Some people do kill themselves. Given the nature of a psychiatric practice today, such a seriously disturbed person presenting in a psychiatrist’s office will be given anti-depressants; but they are not likely to work. What these patients are experiencing is a kind of exaggerated grief. Like other forms of grief, it will get better with time. No one feels like killing himself/herself six months after being jilted. The proper treatment is a closely supervised supportive psychotherapy.
“If the patient does what is necessary (when possible) to redress a loss, the condition will go away relatively quickly. A lover jilted will feel better after about six months, usually, if he/she dates actively (not something that individual is going to want to do.) If the jilted lover mopes around the house indefinitely, recovery can take a year. These figures vary, of course, from one person to another. I don’t think anyone gets over a broken love affair entirely until there is someone else to take the place of the missing lover. Although drugs are given in this situation, their effect is likely to be limited to a placebo response.
“There is a third kind of depression.
“In every kind of depression, the affected individual is likely to be withdrawn and irritable, and unable to take pleasure in the usual activities that always had been pleasurable. Depressed people may develop vague physical symptoms. They tend to ruminate. But there is a third kind of depression that presents with additional symptoms. This is an illness. It tends to run in families and tends to start for the first time in late adolescence or in the twenties—although it can start at any time. Untreated, it is said to last about a year usually. It is likely to recur a number of times during the life of the patient. What sets this kind of depression off from the others is the presence of vegetative symptoms.
“First of all, the depressed person develops a very characteristic sleep disorder. Unless the depression is very severe, that person is likely to fall asleep readily, but will then wake up during the night, sometimes multiple times, feeling agitated and distressed –sometimes from a bad dream. Finally, the depressed person is likely to wake up too early—day after day and week after week—feeling very bad. The particular bad way he/she feels is different from one person to the next. Most people feel sad, but some do not. They may feel agitated, even panicky. That awful feeling fades somewhat during the course of the day; and the evenings may not be too bad. This is called a diurnal variation in mood.
“Another vegetative sign is of a depressed appetite, usually to the point of losing weight. Similarly, there is a loss of sexual interest.
“This third kind of depression requires treatment with the anti-depressant drugs.”
I do not go on to describe the depression that appears as part of a bipolar disease, and the so-called “atypical depression,” which is marked by excessive sleeping and eating. These conditions are real but somewhat less characteristic in presentation—and less common.
I think the distinction between kinds of depression drawn above is a good general guide to determining the appropriate treatment, and, in particular, the need for medication. (c) Fredric Neuman Follow Dr. Neuman's blog at fredricneumanmd.com/blog
