In the United States statistics indicate that 1 in 10 Americans have a depression that results in medical attention.  That attention may be directed to abdominal pain or headaches instead of the depression itself that generated that the symptoms.  The column this week and next will be directed to a description of depression, a concept of how it develops and treatment expectations.

 A description of the depressed person probably isn’t even necessary.  Most everyone knows what a depressed person looks like and how they act.  But with managed care, Medicare, and insurance companies confronting the high cost of depression, a precise description and listing of the symptoms is now necessary in order to get insurance coverage for the treatment of this condition.  It must be realized that depression does not represent a single disease entity and the manifestations may be very different from one person to the next.  Most commonly, the depressed person appears to be in a sad mood.  They have lost interest in their usual activities that formerly brought joy.  Weight loss and loss of appetite occur very frequently but binge eating and massive weight gain is also a manifestation of depression.  There is usually a sleep disturbance most commonly manifest as awakening early in the morning and ruminating for several hours before getting up.  Less commonly, the person has difficulty getting to sleep in the first place.  Fatigue, loss of energy, loss of interest, difficulty concentrating, loss of self-esteem, and the desire to be alone are all listed as manifestations of  a depressed person.  No one person has all of these symptoms and some hide them so well that the actual depression is not really suspected until a suicide occurs.

 The diagnostic manuals list three broad categories of depression.  First, there are the episodes of depression that seem to be related to the person’s activities and the events in their life.  These individuals seem to react with a clinical depression often faulted to or triggered by an event.  Generally, the episodes of depression last approximately six months or less but may occur many times throughout the person’s life.

 The second broad category of depression is the so-called, “dysthymic depression”.  This person seems to be in a low energy, fragile, sad state over a prolonged period of time often years.

 The third broad category of depression is the so called, “manic depressive disorder” or “bipolar disorder” in which the person alternates between periods of extreme depression interspersed with episodes of mania in which they are grandiose in their behavior and very disorganized in their thought processes and behavior.  Manic-depressive disease was the first psychiatric condition for which a specific medical therapy was discovered.  In 1954 Dr. John Cade working in Australia, discovered that lithium worked remarkably well to stop the cycling bouts of depression and mania in people with this disorder.  Fifty years later, lithium still remains the best treatment for this condition.

 Dysthymic disorder is much more difficult to deal with.  The condition in these individuals is chronic, “almost part of their constitution”, and associated with learned behavior that seems to propagate their condition.  Caring and trying is almost like a foreign concept.  Meaningful effective change for the dysthymic individual requires a change in environment that becomes an epiphany in the person’s life.  Examples would be a divorce, a change in job, the relief of a burdensome responsibility or the establishment of new constructive relationships.

 The third broad classification of depression is those individuals who have episodes of depression that seem to be triggered by an event that then impacts the individual for months.  This group includes a so called “seasonal affective disorder” in which individuals seem to become depressed in winter months and postpartum depression whereby a woman becomes non- functional several months after her baby is born.  But most commonly depression is related to some event such as a loss of a loved one, the loss of a job, or a lack of success in an endeavor.  These are by far the vast majority of depression problems.

 It may sound strange to say but the root of all depression is caring.  We humans are equipped with a very large computer with two properties that neither Dell nor Gateway nor IBM has yet to put in their computers.  Our human computers are capable of original thought and they have emotions that result from our caring.  The reason that we cry is because we cared about something that happened.  The reason we become angry is that we cared about something that happened.  The reason we become happy is that we were successful in achieving something we cared about.  The reason we become sad is that something we cared about did not occur the way we wanted.

 Caring can lead to either destructive or constructive behavior.  A person may care so much that they may strike out and become physically violent when someone performs an undesirable act.  The person may care so much that physical harm is done to others when the others don’t perform as desired.  A person may care so much that the pain of their non-success needs to be assuaged with drugs or alcohol.  A person may care so much that they go outside of the socially prescribed relationships to seek happiness.  A person may care so much that they seek added gratification through excessive food when the person’s endeavors are not as successful as desired.  Thus, caring can be a very destructive property of the individual and it is the root from which depression grows.

 The column next week will describe a group of drugs called the selective serotonin reuptake inhibitors (SSRI’s) that are the mainstay of drug treatment for depression in 2003.  This group of drugs is not without its own set of problems but they are by far the best treatment for depression with fewer side effects than any anti-depressive drugs thus far discovered.