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Am I Blue? : Clinical Depression Is An Illness, Not A Mood, And Warrants Medical Attention

<i> Miriam Shuchman is a physician in the Clinical Scholars Program at UC San Francisco Medical Center. Michael S. Wilkes is a physician in the Clinical Scholars Program at UCLA Medical Center. Their column appears monthly. </i>

THE WOMAN WHO entered moved very slowly, as if she were carrying a great burden. She said she felt so sad she could barely move. Three weeks earlier, Monica had been denied a promotion at work, and ever since, she’d been feeling more and more depressed. For the past five days, she had stayed home because she felt so fatigued. Friends and co-workers had called, urging her to get professional counseling. She had come to us at their insistence.

Everyone has bad days, even bad weeks. A major disappointment at work, or in a relationship, can leave one feeling down for quite a while. So it can be difficult to know whether the blue mood is a depression that warrants professional attention or if it’s just temporary sadness. It makes a difference, though, because a severe clinical depression can last for months if not treated.

For Monica, the feelings that began as frustration and bitterness had developed into a full-blown depression over the course of a few weeks. By the time she came for help, she had all the classic physical and mental symptoms: She felt as if she were engulfed by a great cloud of despair. She was losing weight, eating poorly--sometimes just one piece of toast the entire day. She was not sleeping well. At times she felt so hopeless that she considered killing herself. But thoughts of her two teen-age children kept her from attempting suicide.

Clinical depression affects about 6% of the population, according to a National Institutes of Mental Health (NIMH) study. It is a serious illness, like pneumonia or hepatitis, not merely a mood that a person can work through or wish away. As with migraine sufferers, some people can clearly identify the reason they become depressed; others experience depression that seems to have come out of nowhere. Whatever the root cause, once clinical depression strikes, it can result in significant disability. Dr.Ken Wells, a psychiatrist at UCLA Medical Center found, in a recent study, that people with clinical depression suffer more functional impairment--including more days in bed and more time away from work--than people with heart disease, stomach ulcers and chronic back pain.

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Given the extent of the problem, treatment is crucial, and, as is the case with many illnesses, there are a number of treatments available. When suicide is not an imminent threat, most doctors suggest outpatient treatments, such as antidepressant medications, weekly psychotherapy or a combination of the two.

We recommended therapy and medication for Monica. At first she was reluctant to go on the medication; the misconception that depression is a personal problem rather than an illness often makes it difficult for people to accept medical treatment. But as Monica’s feelings of hopelessness continued, she agreed to try nortripeline, one of the most common antidepressants. She began to feel somewhat better after about four weeks, and much better after two months. She decided she didn’t want to return to her old job and was ready to start looking for a new one. We warned her that the depression might recur, since most people who have depression have several episodes during their lives. So far, she’s been fine.

Unfortunately, many people with clinical depression are never treated effectively. Some consider depression a personality flaw that they should be able to solve by themselves, and do not seek help. Or they believe they have another illness, such as the flu. Unfortunately, medical doctors often do not recognize symptoms of depression or recommend treatment. Until recently, it was difficult for even mental health professionals to determine the best treatment for a patient. In the ‘60s and ‘70s, there was a proliferation of antidepressant medications and different forms of psychotherapy but no clear basis for choosing one over another. Then, in the early ‘80s, the National Institutes of Mental Health organized a $14 million study aimed at providing some guidelines. The multiclinic study compared drug treatments, using a standard antidepressant (the drug imipramine) with two types of psychotherapy: cognitive therapy, which relies on the individual to change his or her own thinking habits; and interpersonal therapy, which emphasizes problems in personal relationships.

The results of the study, released last year, showed that for milder cases of clinical depression, patients do equally well with medications or therapy. But for severe cases, the research indicated, drugs work much better than therapy.

The study did not attempt to determine which drug is most effective. Recently, the relatively new drug Prozac has received a great deal of attention. Antidepressants such as imipramine, the drug used in the NIMH study, have been considered effective since the late ‘50s. But in the past two years, Prozac has become the most-prescribed antidepressant. It is as equally effective as the older drugs, but is preferred by some doctors because it has fewer side effects; many antidepressants can cause dry mouth and eyes, sleepiness and constipation.

However, Prozac has recently come under renewed scrutiny, because some researchers claim that the drug can lead to intense and violent suicidal thoughts and self-destructive acts. Currently, doctors are being more cautious in prescribing it, though it is still widely used.

Not all depression warrants medication. As awareness of this illness has increased, so have the number of treatment alternatives. Some people who routinely become depressed during thewinter months--a condition known as seasonal affective disorder--improve significantly when they sit under high-powered, specially designed lamps for two to six hours a day. Though doctors are unsure exactly how such light therapy works, several studies conducted since the mid-'80s have proven its effectiveness. Other research suggests that regular exercise has an antidepressant effect. And at UC San Diego, Dr. Christopher Gillin has been testing the hypothesis that people with clinical depression improve when they sleep less. Patients participating in Dr. Gillin’s research are kept awake until much later than their normal bedtime. “About 50% of patients show improvement,” he says.

But what about feelings of depression that don’t qualify as psychiatric disorders? Most people have mild depressions, which often hit hardest around the holidays. What works to cure the blues?

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--Get outdoors and take a walk or run. Exercise is the cheapest anti-depressant.

--Call a friend and tell him or her how you’re feeling. Sometimes just talking about sadness can help make it dissipate. If you’re concerned about burdening your friends, try the Good Samaritans or similar hotline groups.

--Don’t reach for a drink to wash away the blues; alcohol is a depressant and will only make you feel worse. Try a cup of coffee or tea instead.

--If you begin to feel extremely hopeless, go to your local clinic or emergency room and speak to the psychiatrist on call. That’s what they’re there for.

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