The Many Faces of Depression  

      Getting proper help for depression begins with a proper diagnosis. This is easier said than done, since depression, like the mythological Hydra, is a many-headed beast. There are many types of depressive disorders, each of which contains a multitude of symptom patterns and representations.
      What follows is a broad overview of the most common depressive disorders as listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). The types that I will cover are:

• major depression
• dysthymia
• manic-Depression
• cyclothymia
• post-partum depression
• seasonal affective disorder (SAD)
• existential depression
• mood disorders due to a medical condition
• medication-induced depression
• substance-induced mood disorder

      For those who have not studied psychology or psychiatry, I hope that this synopsis provides you with an understanding of the brain imbalances that may affect you or your loved ones.

      This is the mood disorder from which I suffered. Its symptoms are described in the previous link, "FAQ's about depression." Along with manic-depressive illness, clinical depression is the most serious of the mood disorders and can result in suicide when left untreated.

      In addition to major depression, there exists another type of depressive illness-dysthymia-that is far less severe, though crippling in its own way. Dysthymia consists of long-term chronic symptoms that do not disable, but keep one from feeling really good or from functioning at full steam. Physically, it is akin to having a chronic low-grade infection-you never develop a full-blown illness, but always feel a little run down.
      Although dysthymia implies having an inborn tendency to experience a depressed mood, it may also be caused by childhood trauma, adjustment problems during adolescence, difficult life transitions, the trauma of personal losses, unresolved life problems, and chronic stress. Any combination of these factors can lead to a enduring case of the blues.
      Some of the most prominent symptoms of dysthymia are:

• depressed mood for most of the day, for more days
   than not, for at least two years.
• difficulties in sleeping.
• difficulty in experiencing pleasure.
• a hopeless or pessimistic outlook.
• low energy or fatigue.
• low self-esteem.
• difficulty in concentrating or making decisions.
• persistent physical symptoms (such as headaches,
  digestive disorders or chronic pain) that do not
  respond to treatment.

      A dysthymic disorder is characterized not by episodes of illness but by the steady presence of symptoms (see diagram on next page). Because dysthymia does not incapacitate like major depression, as a rule, dysthymic people do well in psychotherapy (medication can also be used). During stressful times, a person with dysthymia may be catapulted into a major depressive episode, called "double depression."
      Dysthymic disorder is a common ailment, affecting about 3-5 percent of the general population. Unfortunately, because dysthymia is not as severe as clinical depression, the condition is often undiagnosed or dismissed as a case of psychosomatic illness. ("Your symptoms are all in your head," is the all-too-common response from doctors.) Perhaps the most famous dysthymic is Eeyore, the despondent and downcast donkey in A.A. Milne's Winnie the Pooh. If you identify with Eeyore (or feel down in the dumps most of the time), it is important that you consult a qualified mental health professional who can make a correct diagnosis. In addition, you can use the wellness strategies described in the "Staying Well" link on this web site.
      Having a dysthymic temperament also brings with it positive traits. Dysthymic individuals can be serious, profound, deep, prudent, dependable, industrious, patient and responsible.

      Although manic-depressive illness (which affects two to three million people) is less common than major depression, it maintains a high profile because of the many creative artists who have suffered from it. Examples include Edgar Allen Poe, Tennessee Williams, Ezra Pound, Virginia Woolfe, Vincent Van Gogh, Alfred Tennyson, Cole Porter and Robert Schumann. In recent times, celebrities such as Abbie Hoffman, columnist Art Buchwald, actress Patty Duke, actress Margot Kidder, and CNN's Ted Turner have been similarly afflicted.
      Manic depression has two distinct sides-the depressive state and the manic state. Mania is a seemingly heavenly state of mind in which all the world is beautiful and everything seems possible. Here are some of the most common characteristics of mania:

      As Kay Redfield Jamison, a psychologist who is diagnosed with manic depression, writes in her memoir An Unquiet Mind:

When you're high it's tremendous. The ideas and feelings are fast and frequent like shooting stars and you follow them until you find better and brighter ones. Shyness goes. The right words and gestures are suddenly there, the power to captivate others is a felt certainty. Feelings of ease, intensity, power, well-being, financial omnipotence and euphoria pervade one's marrow.

      Upon hearing this description of mania, people often respond, "If this is a disease, where do I sign up for it?" The problem with mania, however, is that due to the impulsivity and poor judgment that it brings, an episode can wreak havoc on family, friends, the community and the law. Moreover, when the high inevitably wears off, the individual comes crashing down into a state of total darkness and despair. As Jamison describes:

A floridly psychotic mania was followed, inevitably, by a long and lacerating black, suicidal depression. Everything -every thought, word and movement-was an effort. Everything that once was sparkling now was flat. I seemed to myself to be dull, boring, inadequate, thick brained, unlit, unresponsive, chill skinned, bloodless, and sparrow drab. I doubted, completely, my ability to do anything well. It seemed as though my mind had slowed down and burned out to the point of being totally useless.

      A well-known myth that perfectly describes the manic depressive's fall from grace is the myth of Icarus. Icarus, son of the Greek inventor Daedalus (who built the labyrinth), was given wings of wax by his father. Enamored of his new found ability to fly to great heights, Icarus ignored his father's warning and in a moment of ecstasy flew too close to the sun. The heat of the sun melted the wax which held his wings together, and Icarus crashed into the sea.
      The alternation of mania and depression illuminates a second aspect of manic depression-its cyclic nature. Periods of creativity, productivity and high energy alternate with times of fatigue and apparent indifference. Mania leads to depression, which leads to mania which becomes depression, etc. This extreme flip-flop of mood between peaks and valleys is extremely dangerous, as shown by the fact that 20 to 25 percent of untreated manic depressives (including many of the artists listed earlier) commit suicide.
      Fortunately, manic depression is highly treatable, due to the discovery of lithium, a simple salt that in 1949 was accidentally found to have a mood-stabilizing effect on bipolar individuals. The downside of lithium treatment is that therapeutic levels of lithium are dangerously close to toxic levels. Lithium poisoning affects the brain and can cause coma and death. Thus, in the initial stages of treatment, lithium concentration in the blood must be frequently monitored. After the lithium blood level stabilizes, levels can be checked every six months.
      The side effects of lithium can include hand tremors, excessive thirst, excessive urination, weakness, fatigue, memory problems, diarrhea, and possible interference with kidney function. Lithium is often ineffective in treating bipolar patients who are rapid cyclers-those who experience four or more manic-depressive cycles per year. For these and other patients who fail to stabilize on lithium, the drugs Depakote and Tegretol (originally anti-seizure medications) are also available. For some doctors, Depakote is now the drug of choice, rather than lithium, because its long-term side effects are considered safer.
      In addition to taking medication, bipolar individuals can employ a number of preventive strategies to decrease the likelihood of having a full-blown manic attack.

1) Recognize the early warning signs of mania-e.g., insomnia, surges of energy, making lots of plans, grandiose thinking, speeded-up thinking, overcommitment, excessive euphoria, spending too much money, etc. Let friends and family know of these symptoms so that they can also become alerted to the start of a manic episode.

2) Create a stable lifestyle in which you keep regular sleep hours. Studies show that intervals between manic episodes are considerably longer in those people who live in stable environments. In addition, eat a diet that is high in complex carbohydrates and protein, avoiding foods such as simple sugars that can cause ups and downs. Alcohol and caffeine should also be avoided.

3) Use planning and scheduling to stay focused and grounded. Make a list of things to do and stick to it.

4) Try to engage in a daily meditative activity which focuses and calms the mind. If you are too restless for sitting meditation, go for a leisurely walk, taking long, deep breaths along the way.

5) Refrain from taking on too many projects or becoming over- stimulated. If you feel an excess of energy starting to overtake you, channel it into productive physical activities such as doing the dishes, mopping the floor, cleaning out the basement, weeding a garden, etc.

6) Psychotherapy and support groups can help you to explore the emotional aspects of the illness, as well as provide support during times of stress.

7) If you feel that things are getting out of hand, call your doctor or therapist. This is especially true if you start losing sleep, as sleep deprivation is one of the major contributors to mania.

8) Ask a good friend or family member to track your activity level. Sometimes a manic episode can "sneak up on you," and an objective person may be able to spot it before it gets out of hand.

      Books, organizations and support groups for manic depression are listed in the Resources for Wellness section at the back of the book.

      Cyclothymia is a milder form of manic depression, characterized by hypomania (a mild form of mania) alternating with mild bouts of depression. The symptoms are similar to those of bipolar illness but less severe. Many cyclothymic disorder patients have difficulty succeeding in their work or social lives since their unpredictable moods and irritability create a great deal of stress, making it difficult to maintain stable personal or professional relationships.
      Cyclothymic persons may have a history of multiple geographic moves and alcohol or substance abuse. Nevertheless, when their creative energy is focused towards a worthwhile goal, they may become high achievers in art, business, government, etc. (The cycles of cyclothymia are far shorter than in manic depression.) The ability to work long hours with a minimum of sleep when they are hypomanic often leads to periods of great productivity.
      If you identify with the diagnosis of cyclothymia, you may use the wellness strategies described for manic depression, as well as those in the "Staying Well" link to elevate and stabilize your mood. If your highs and lows begin to intensify, seek treatment with a psychiatrist or mental health professional.

      In the period that follows giving birth to a child, many women experience some type of emotional disturbance or mental dysfunction. A large percentage of these "baby blues" are characterized by grief, tearfulness, irritability and clinging dependence. These feelings, which may last several days, have been ascribed to the woman's rapid change in hormonal levels, the stress of childbirth, and her awareness of the increased responsibility that motherhood brings.
      In some cases, however, the baby blues may take on a life of their own, lasting weeks, months and even years. When this occurs, the woman suffers from postpartum depression-a syndrome very much like a major depressive disorder. This depression may also be accompanied by anxiety and panic. In extreme cases, symptoms may include psychotic features and delusions, especially concerning the newborn infant. There may be suicidal ideation and obsessive thoughts of violence to the child.
      It is estimated that approximately 400,000 women in the United States experience postpartum depression, usually six to eight weeks after giving birth. Postpartum depression is a treatable illness that responds to the following modalities:

• recognizing and accepting the disorder.
  
• breaking negative thought patterns.
  
• creating support systems.
  
• reducing stressors in one's life.
  
• exercise and right diet.
  
• medication (antidepressants and antianxiety drugs).
  
• psychotherapy.
  

      A good introduction to this often undiagnosed disorder is contained in the book This Isn't What I Expected by Karen Kleiman, M.S.W. and Valerie Raskin, M.D., mentioned earlier. You might also want to visit the web site of the organization Depression After Delivery ( http://www.behavenet.com/dadinc ).

"There's a certain Slant of light,
Winter Afternoons-
That oppresses, like the Heft
Of Cathedral Tunes-
Heavenly Hurt, it gives us."
Emily Dickinson

      Patients with Seasonal Affective Disorder tend to experience depressive symptoms during a particular time of the year, most commonly fall or winter. They often begin in October or November and remit in April or May. The symptoms of SAD, also known as "winter depression," are listed below.

• altered sleep patterns, with overall increased amount of sleep.
  
• difficulty in getting out of bed in the morning and getting going.
  
• increased lethargy and fatigue.
  
• apathy, sadness and/or irritability.
  
• increased appetite, carbohydrate craving and weight gain.
  
• decreased physical activity.
  

      Researchers believe that Seasonal Affective Disorder is caused by winter's reduction in daylight hours which desynchronizes the body clock and disturbs the circadian rhythms. Winter depression is usually treated by morning exposure to bright artificial light (see pg. 273 for addresses of light box companies). By providing appropriately timed light exposure, the body's circadian rhythms become resynchronized and the symptoms of SAD resolve.
      In addition, it is important for the person with SAD to get as much natural light as possible. Here are some suggestions:

• Light up your homes as much as you need to. Use white wallpaper and light-colored carpet instead of dark paneling and dark carpet.
  
• Choose to live in dwellings with large windows.
  
• Allow light to shine through doors and windows when temperatures are moderate. Trim hedges around windows to let more light in.
  
• Exercise outdoors.
  
• Set up reading or work spaces near a window.
  
• Ask to sit near a window in restaurants, classrooms or at your workplace.
  
• Arrange a winter vacation in a warm, sunny climate.
  
• Put off large undertakings until the summer.
  

      Although the most common form of recurrent seasonal depressions in northern countries is the winter SAD, researchers at the National Institute of Mental Health have uncovered a type of summer depression that occurs during June, July and August. Summer SAD tends to occur more in the southern states such as Florida, as well as in Japan and China. Summer depressives frequently ascribe their symptoms to the severe heat of summer, although in some instances the depressions may be triggered by intense light.
      For further information or support about SAD, contact your doctor or visit the Web site of the Society for Light Treatment and Biological Rhythms
( http://www.websciences.org/sltbr ). Norman Rosenthal's seminal book Winter Blues is also a good resource.

      A specific kind of depression, known as existential depression, is brought on by a crisis of meaning or purpose in one's life. Any significant transition, especially a change of roles in family or work, can trigger this crisis in meaning. A well-known account of existential depression occurred in the life of the famous Russian novelist Leo Tolstoi. In mid-life, while enjoying health, wealth, and great literary fame, Tolstoi fell into a deep despair as he asked himself, "Is this all there is?" Out of his quest for something more, Tolstoi underwent a religious conversion and formulated a philosophy of nonviolence, renunciation of wealth, self-improvement through physical work, and nonparticipation in institutions that created social injustice. Tolstoi's ideas had a profound influence on many social reformers, including Mahatma Gandhi and Martin Luther King, Jr.
      The importance of dealing with existential issues should not be underestimated. A number of clinicians have reported that depression (as well as Chronic Fatigue Syndrome) has a strong connection with a person's lack of success in finding his passion-i.e., not being involved in work/activities that feed the core self. After all, Sigmund Freud defined mental health as "the ability to work and to love." If either of these two essential needs is missing, even a person with normal brain chemistry is going to feel out of kilter.

      Clinical depression commonly co-occurs with general medical illnesses, though it frequently goes undetected and untreated. While the rate of major depression in the community is estimated to be between 2-4 percent, among primary care patients it is between 5-10 percent. For inpatients, the rate increases to between 10-14 percent.
      Treating the co-occurring depressive symptoms can improve the outcome of the medical illness while reducing the emotional and physical pain and disability suffered by the patient. Here are some medical conditions that have been implicated as triggering depressive symptoms:

• endocrine conditions (hypothyroidism, etc.).
  
• neurological disorders such as brain tumors.
  
• encephalitis.
  
• epilepsy.
  
• diseases that cause structural damage to
  the brain.
  
• viral and bacterial infections.
  
• inflammatory conditions such as rheumatoid arthritis and lupus.
  
• vitamin deficiencies (especially vitamin B12, vitamin C, folic acid and niacin).
• heart disease.
  
• stroke.
  
• diabetes.
  
• kidney disease.
  
• multiple sclerosis.
  
• cancer.
  

      Anyone who suffers from one of these disorders should treat the underlying illness medically and pursue psychotherapy or counseling if depression accompanies the physical illness.

      Many people do not realize that a number of common prescription drugs have side effects that can induce depression. Thirty years ago, my mother went into a long-term depression as a result of a reaction to the drug Resperine, a high blood pressure medication. Similarly, my own depression was accelerated by my reaction to large doses of antibiotics given for a leg infection. Prescription drugs with depressive side effects include:

• cardiac drugs and hypertensives
  
• sedatives, steroids
  
• stimulants
  
• antibiotics
  
• antifungal drugs
  
• analgesics
  

      It may be worthwhile to consult the Physician's Desk Reference (PDR) or books such as Worst Pills, Best Pills (by Wolfe, Sasich, and Hope) to learn if depression is a potential side effect of a medication you are taking. In addition, taking recreational drugs or being exposed to toxic chemicals in the environment may also have an adverse effect on mood.
      Usually, stopping the intake of the offending substance will eliminate the symptoms (as happened in my mother's episode). If depressive symptoms caused by the substance linger, then psychological treatment may be necessary.

      If you're depressed, you're more likely to use alcohol and other drugs to medicate your feelings. And if you use alcohol and other drugs, you are more likely to develop depression. Thus alcohol and drug abuse can be both the cause and result of clinical depression.
      When you are both depressed and dependent on alcohol or drugs, you are given a "dual diagnosis." A dual diagnosis simply means that you suffer from both a psychiatric disorder (it may a bipolar disorder or depression) and chemical dependency. Having a dual diagnosis complicates the healing process, since it means that you have to overcome two major illnesses in order to get well. Fortunately, many outpatient and resident treatment centers specialize in treating individuals with dual diagnoses. These centers are usually covered by insurance and are able to offer long-term treatment. Check with your local hospital or mental health clinic to learn who offers dual diagnosis treatment in your area.