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- David Joffe

Overview of Clinical Depression

Copyright (C) David Joffe 1998
Created 29 July 1997
Revision 1.1, 21 November 1998
You may make copies of this document and redistribute it, so long as the content remains unmodified.

I am not a qualified health-care professional, and the information in this document should be taken as such. Although I have tried to be accurate, you should always get advice from a qualified person when seeking help.

Abstract: This document is intended to be an introduction to and overview of clinical depression. It covers the major types of depression, including the symptoms and believed causes, how depression is and how it used to be treated, and what attitudes and ignorances are exhibited by society regarding depression. The hypothetical link between creativity and depression is discussed, and what to do if someone you know is depressed or suicidal is also covered. The author's interest in the topic stems from having suffered from depression in the past.

Keywords: Clinical depression, Unipolar, Bipolar, Dysthymia, suicide, serotonin.

1. Introduction: what you should know and why

Untreated depression is the number one cause of suicide, and suicide is the third leading cause of death in the United States, behind accidents and homicide. Most people, even if they are not personally affected by depression, will most likely at some stage or another have to deal with a person who is. Thus it is extremely important that everyone should know how to handle such a situation, just as it is important for every person to know basic lifesaving procedures such as CPR. Because of various attitudes entrenched in modern western culture, too many people regard mental health as being somewhat less important than physical health, and too many lives are destroyed because of this outlook.

2. Clinical Depression

2.1 What is clinical depression?

Generally speaking, the term clinical depression refers to any depression that requires some form of treatment. It is normal for people to feel depressed when something bad happens, such as the death of a loved one. This type of depression normally goes away after a couple of weeks; but sometimes it persists. It can last for periods of six months or more, and then it is classified as clinical depression.

There are three main types of depression; unipolar disorder (major depression), bipolar disorder (manic depression) and dysthymia (prolonged sadness). People with unipolar disorder experience recurrent attacks, or "episodes", of severe depression that can last anywhere from a few hours to a few months. Sufferers typically experience feelings of complete hopelessness, worthlessness, loss of motivation and often feel suicidal. Sufferers of manic depression experience depression episodes of the same degree, but also have episodes of mania in-between these. Associated with mania is a feeling of intense euphoria (a "high".) During manic episodes sufferers may go for days with no sleep and almost no food, show incredible strength, and often have to be physically restrained. Feelings of total indestructibility are common, and the manic person may believe for example that not even moving cars can stop him or her, or that he or she can fly. They experience delusions and hallucinations and sometimes talk so fast that their speech becomes illegible. In extreme states of mania sufferers can believe that they have some sort of personal communion with God or with celebrities (Fieve (1989)). Amazingly, most of these same people are completely normal during or after treatment of the condition. Dysthymia does not cause any such intense attacks, but rather a prolonged general feeling of being unable to enjoy anything, and a feeling that one is just "going through the motions" while doing ones everyday activities. It is worth noting that manic depression and major depression seem to have different underlying medical causes, as each responds to different medications. Manic depression is normally treated with lithium.

Symptoms of depression:

About 12 percent of people suffer from clinical depression. Depression occurs evenly amongst all races and genders, with the exception of bipolar disorder, which seems to occur more frequently amongst women. Depression is also common in children, and can occur at ages as young as 4 or 5 years old.

2.2 What causes depression?

It used to be more commonly believed that depression was caused by psychological reactions to a person's environment. Research today is generating more and more evidence that physiological factors are strongly involved, although opinions today are still widely divided within the field as to how much of depression is psychological and how much is physiological. It seems, however, that it is a combination of both; what makes this tricky is that almost every case seems to be unique.

What is known is that one major cause of depression is an imbalance in certain chemicals in the brain cells (neurons) called neurotransmitters, which carry signals between brain cells. The particular neurotransmitter that depressives do not have enough of is serotonin, although another, norepinephrine, is also known to play a part. There is strong statistical evidence showing that depression can be inherited from ones parents. Studies of MRI (Magnetic Resonance Imaging) scans have shown that the brains of depressed people function very differently to those of non-depressive people. Still more recent studies have shown that a small section of the brain known as the subgenual prefrontal cortex is significantly smaller in depressed patients with a family history of depression than in non-depressives (Gorman (1997)). The aforementioned part of the brain is known to be associated with the control of emotions. Still other studies have shown a significant link between suicidal and aggressive behavior and a low concentration of a chemical (5-hydroxyindoleacetic acid) in the spinal fluid (Feiger (1993)). There are also some chemical tests for depression discussed by Feiger (1993), although they are not accurate enough and are too expensive to warrant their use for common diagnosis; besides, diagnosing depression is normally quite easy anyway, and can be done just by asking the patient a series of questions..

Depression is also very strongly linked to substance abuse, such as drug-addiction and alcoholism, although this is not discussed at any length in this document.

2.3 Treatments old and new

The Middle Ages was not a good time to be a depressive. The mentally ill were frequently interned and brutalized at Bethlehem Hospital (also known as "Bedlam"), and this insane asylum was a favorite Sunday excursion spot for Londoners who came to look at the patients through the iron gates. People were driven from towns, ridiculed, beaten, or stoned; women were often thought to be witches and were burnt at the stake or drowned. In the early 1800's, common treatments included using chains, beatings, bloodletting and sudden ducking in cold water.

Luckily, times and perceptions have changed a lot since then, although depression is still very much misunderstood. As recently as a couple of decades ago, depressives were still very often being misdiagnosed and/or hospitalized as schizophrenics. Around the 50's and 60's the classes of antidepressants known as the tricyclics and the Monoamine Oxidase Inhibitors were first developed, and along with Lithium represented the first major medical breakthroughs in chemical treatment of depression. The most commonly prescribed antidepressants today are of a newer class known as the SSRI's - the Selective Serotonin Re-uptake Inhibitors; these generally are more specific and have fewer side effects than the older types, and are not addictive. Antidepressants can take up to six weeks to become properly effective. About 70 percent of depression is treatable, although normally a bit of experimentation must be done to find an antidepressant that works for a specific individual. Treatment should also normally be done together with counseling.

Another method of treatment that was more popular earlier in this century, although it is no longer used as much as it used to be, is Electro-Convulsive Therapy (ECT), or electroshock therapy. Very high voltages are applied to the brain for short periods, which normally results in, say, a manic patient calming down. ECT seems to work in bad cases of depression that refuse to respond to any other treatment. In the first half of the 1900's frontal lobotomies were also performed for mental illnesses, although this is now widely regarded as having been a very bad idea.

2.4 Ignorance

Between 65 and 70 percent of depression still goes untreated (Fieve (1989)). The reasons are many, but one of the biggest factors is ignorance. Sadly, many people are raised with notions that depression is a moral weakness, an inability to cope, or even that depression is purely a spiritual problem. Sometimes parents lead children to believe that they are depressed because they do not have enough faith in God. Ignorance about antidepressants also causes people to hold back on getting treated, for example many people believe that antidepressants are addictive. 75 percent of Americans believe that someone with depression can get better just by being more positive (Wing of Madness: A Depression Guide). This is a dangerous view. Besides the obvious effects of such views, such as general human suffering or suicide, there are other reasons why someone with depression should see a doctor. Depression is sometimes a symptom of another illness, such as heart disease, thyroid dysfunction or cancer. The depressive person can not talk him or her self out of it, and cannot "snap out of it". "Looking on the bright side" cannot cure depression, and depressives can not feel better just by trying harder to feel better.

2.5 Depression and Creativity

Many people believe that there is some sort of link between depression and creativity. The notion of the "suffering artist" afflicted with depression may seem to be an over-romanticized dramatization of the issue, but statistics from studies do suggest strongly that such a link may very well exist. In one study by psychologist Kay Jamison of 47 painters, writers and sculptors, it was found that eighteen of them had been treated or hospitalized for depression - a rate of 38 percent, which is more than six times that of the general population (Fieve (1989)). One possible other reason why this figure might be so high is that depressive people may be more inclined to choose careers such as art where their behavior and moods are considered more "acceptable" than in fields such as accounting.

Many famous artists who lived in the past strongly displayed symptoms of depression, with some of the more well known of these cases being Vincent van Gogh, Sylvia Plath and Wolfgang Amadeus Mozart. There are many other artists that most people do not know were either hospitalized or attempted suicide. Amongst these are Edgar Allen Poe, Lord Byron, William Blake, John Keats, TS Elliot, Mark Twain, Noel Coward, George Frederic Handel, Charles Dickens, Robert Louis Stevenson, Ernest Hemingway and Tennessee Williams. Abraham Lincoln, Theodore Roosevelt and Winston Churchill are also known to have been depressives. Amongst the more famous confirmed manic depressives who are still living are Peter Gabriel (musician), Spike Milligan, Axl Rose (musician), Ted Turner and Robin Williams. Confirmed unipolars who are still living include Roseanne Arnold (actress, writer, comedienne who also has multiple personality disorder and obsessive compulsive disorder), Kitty Dukakis and James Taylor (musician) (The FAQ). Artistic people are often unwilling to get their depression treated for fear that it may destroy their ability to be creative, although whether or not this is so has not been proved; in fact, in many cases, the opposite seems to be true.

2.6 What to do, and what not to do

When someone you know is depressed, it is important to provide the right type of support. Listen to the depressed person - you don't need to have any solutions for them, just listen. Be supportive, and sympathetic. Find out whether or not there are support groups in your community. Don't criticize the depressed person. Don't take the person's behavior personally, and don't feel responsible for their depression. Don't patronize or "baby" the depressed person. Don't lose your temper - depressed people can be irritable, inhibited and antisocial, so try be patient with them and try to understand and remember that the cause for their behavior is the disorder.

2.7 Warning signs of suicide

Firstly, all suicide threats should be taken seriously.

Here is a list of the most common warning signs of suicide (Fieve (1989)):

The suicidal person may give away some things that are important to him or her; they may make out a will or take out life insurance. A history of suicide attempts is also a strong indicator. Depressed people should be watched especially closely if they have lost something important such as a friend, a spouse or a job. An angry argument can also trigger a suicide attempt; especially with teenagers. The suicidal person may withdraw from relationships with loved ones; and may make statements indicating feelings of worthlessness.

If you suspect someone is considering suicide, ask him or her about it. Most people will not volunteer such information, but will answer honestly if asked. Ask how long the person has been considering suicide, and find out if there is a definite plan and means to do so. Listen to the person, but don't make judgments. Always try to get the person to a psychiatrist, doctor or hospital as quickly as possible, or call a crisis hotline.

Most suicides can be prevented.

3. Summary

This document began by explaining what depression is, what its symptoms are, and how it feels to the sufferer. Some reasons were given as to why the majority of cases of depression go untreated. Treatments, both modern and historical, were discussed, as well as the possibility of a link between creativity and depression. Common existing ignorances that depressives have to deal with were discussed, and a few instructions on how to deal with a depressed or suicidal person are given.

Unfortunately, depression is far too broad a topic for a document as brief as this one to do anything much more than lightly touch upon most of the issues. The link of depression to substance abuse deserved more attention than it received here, as well as the role of psychological treatment of depression and psychotherapy. Lithium as a treatment for manic depression also warrants further discussion. The topic of remission (why in many cases antidepressants lose some of their effectiveness after initial positive effect) was not covered at all. How depression is handled in the workplace, by the law, by insurance companies, and as a disability were not discussed. Neither were the topics of misdiagnosis, underdiagnosis, overprescribing, hospitalization, and other types of depression such as seasonal depression, postmenstrual depression or postnatal depression. The treatment of depression in children and the role of the family is also a large topic on its own. The somewhat huge impact on the economy from both treatment of depression and lost work hours is not discussed either.

4. References

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