Last week’s column describes the concept that most depression results from destructive caring.  The sequence leading from a normal state to one of depression can be illustrated by the gentleman described below.

 The patient was a 35 year old gentleman who was an executive in a computer component company.  He had a Masters in Business Administration at an excellent school and had taken the position with the computer company thinking that the company would grow and he would have a financially secure future.  He had a wife and three children, ages 4, 6, and 9.  His wife worked as a secretary and the children were in day care or school until both parents got home in the evening.  The patient had always been a hard working individual, was very responsible, and was  very attentive to both his wife and his children.  His wife was also a very caring individual but quick to criticize and point out mistakes, needs, or inadequacies.

 As most everyone knows, the computer industry has hit hard times.  What looked like a previously thriving company with more than one hundred employees is now down to 18 employees and the patient’s salary not only did not increase, it actually was required to be decreased if he was going to maintain his employment.

 The initial event leading to this gentleman’s depression was a sick child.  The four year old developed an asthmatic condition requiring hospitalization with unexpected bills and medical expense.  Finances were already difficult and on one occasion when he expressed concern over the cost of medications, his wife made a caustic comment about how inadequate his salary was.
This stinging remark lead to a verbal exchange that was less than pleasant.  Over the next several months, there were more such heated exchanges, each one adding to a strained relationship.  The intimacy in his marriage was lost, he felt inadequate in his vocational endeavor, the child continued to remain ill and he was seen in the clinic because of abdominal pain.  He was diagnosed as having an ulcer which could be easily treated; but in addition it was noticed that he all the classical findings of depression, including sleep disturbance, disruption of his social contacts, weight loss and a very sad melancholy mood.  When asked whether he had considered suicide, he stated that he would never do it but had thought about it.  He stated that he did have a handgun and could end things in a hurry.

 Changing details slightly, this story can apply to many, many people that have depression.  The basic problem is that they care about their family, friends, job, and children but they encounter a series of disappointments that may be very real and understandable or may be only understandable to the person feeling the disappointment.  No matter what the cause, his caring was acting like the racing engines on a car stuck in the snow.  Sometimes no matter how fast you spin the wheels, you stay right where you are.

 As a major manifestation of his destructive caring, he was becoming angry as his frustration grew.  Most people would like to believe that they are smarter than the average brick but it is amazing how many people continue to believe that heated, angry exchanges will solve a problem.  They somehow have missed the clear fact that heated, angry, verbal or physical exchanges simply recreate their problem in greater complexity.

 So what do the SSRI’s do?  Over the past hundred years, healthcare providers have theorized that depression results from too much or too little of certain chemicals in the brain.  One of these chemicals is called serotonin.  It is a messenger chemical that is released by one cell to tell another cell to do something.  One of theories of depression suggests that the person doesn’t have enough serotonin, so their brain begins to malfunction.  If there was something that would increase the amount of serotonin that the brain had to release perhaps the depression would get better.

 To make a long story short, that is what the SSRI’s do.  SSRI is the abbreviation for “selective serotonin reuptake inhibitor”.  When a nerve cell releases serotonin the cell has a pump which quickly takes up the sreotonin just released.  This way the massage to to next cell appears as a quick short nudge to do something.  The SSRI’s prolong the time that the serotonin is in contact with the receiving cell thereby applifying the message. Specifically, they increase the concentration and the length of time that serotonin is allowed to stimulate a receiving cell.

 Over the past fifteen years, six products have been released on the market after the introduction of Prozac in 1987.  Prozac just went off of patent in the past year but there are five other products called Paxil, Zoloft, Luvox, Celebrex, and most recently Lexapro.  Lexapro perhaps has certain advantages with decreased side effects. Any one of these products is effective in 70% of the people who use them.

 Basically, what the SSRI’s do is allow the person to care in a constructive manner by stoping the engine-racing-behavior.  Exactly how they work is still not understood.  Generally the medications have an increasing benefit for about three weeks and then the benefits seem to be maintained as long as the person uses the medication.  For most people, the medications can be tapered off after three to six months and normal state maintained thereafter.  Repeated use of the medication one, or two, or three years apart is common.

 The great benefit of the SSRI’s is the low side effect profile.  Even in large overdoses, fatal side effects are not expected.  Some few people do become slightly sedated with these medications but this generally will wear off over several weeks.

 The medications are more or less completely eliminated from the body within two weeks of the time that they are stopped and long term chemical side effects are not an expectation.

 Impairment of sexual function is a side effect that occurs in a significant portion of people who use these medications.  Decreased sexual desire is the most common complaint that the patients or their mates have when these medications are used.  Since the sexual dysfunction that comes with depression can be profound trying to separate out which part of the problem is related to the depression and which part to the medication can be difficult.  Generally, adjustment of dosages and various other steps available to your local clinic can help deal with this side effect in a constructive manner.

 In the case of the gentleman described at the start of this column and SSRI was started.  In the course of about three weeks, his symptoms improved substantially.  He has continued on the medication now for an additional four months and is contemplating stopping it in the near future.  While he acknowledges that his wife still makes what he considers to be offensive and degrading comments, he says he now has time to react in a constructive manner rather than pour fuel on the fire.  He does seem to smarter than the average brick.  He said he recognized that he couldn’t change his wife, but he could change the way he responded to her comments.

 On Saturday, January 18th, 2003, there will be a discussion of depression, its roots, and how to treat it at the Medicine Rock Café in Gettysburg, SD at 10:00 AM