Are you depressed? For real?

     “I’m so depressed!” What does that mean when people say that? Sometimes people mean they are really bummed out by present circumstances and just generally aggravated. That is not clinical major depression. Clinical major depression is a serious and potentially life-threatening syndrome that has affected people since the beginning of time and will persist forever. In today’s column, I will briefly explain the definition of depression and describe current treatment modalities. As a practicing internist for 27 years, I diagnosed and treated many patients with mild to moderate depression and a few with severe depression. During my 5-year stint as Medical Director at the Massachusetts Mental Health Center and New England Deaconess Hospital psychiatry units in Boston, I cared for many severely depressed patients who could no longer function safely at home and required hospitalization. I learned a great deal working with these patients. Depression is unfortunately really common. Annually an estimated 11 million U.S. adults aged 18 or older had at least one major depressive episode with severe impairment, representing 4.5% of all U.S. adults. An estimated 3.2 million adolescents aged 12 to 17 in the United States had at least one major depressive episode representing 13.3% of the U.S. population aged 12 to 17.

     Though we are accustomed to trying to put illnesses in a box to conveniently label them, depression like all mental illnesses, exists on a spectrum from very mild to life threatening. At Arcadia, we recognize how behavioral health issues complicate physical health issues and we adjust our risk algorithms accordingly. Several of our customers have asked us to use our tools in order to help them identify and assist people with behavioral health issues.

     Lest you think depression is an invisible entity through history and to the present, here is a short very incomplete list of famous people who struggled with depression: Abraham Lincoln, Winston Churchill, Isaac Newton, Vincent Van Gogh, Ludwig Von Beethoven, Lady Gaga, Gwyneth Paltrow, Bruce Springsteen, Michael Phelps, Jon Hamm, J.K. Rowling, Robin Williams, Ellen DeGeneres, Beyonce, Princess Diana. Depression has long been tainted by stereotype and stigma, and part of my goal here is to lift that off and shine light.

 Here are some quotes from famous people related to their experience with depression:

•  Abraham Lincoln, “If what I feel were equally distributed to the whole human family, there would not be one cheerful face on earth.”
•  Dwayne Johnson, “I found that, with depression, one of the most important things you could realize is that you’re not alone.”
•  Lady Gaga, “I’ve suffered through depression and anxiety my entire life, I still suffer with it every single day.”
•  Robin Williams, “All it takes is a beautiful fake smile to hide an injured soul and they will never notice how broken you really are."
•  J.K. Rowling, “We’re talking suicidal thoughts here, we’re not talking ‘I’m a little bit miserable.”
•  Michael Phelps, “I said to myself so many times, ‘Why didn’t I [get help] 10 years ago?”
•  Kristen Bell, “Anxiety and depression are impervious to accolades or achievements. Anyone can be affected, despite their level of success or their place on the food chain.”
•  Anne Hathaway, "I disliked myself so intensely. It was just a mindset. I didn't know how to love myself. I didn't know how to love anybody." 
•  Chrissy Teigen, “Postpartum does not discriminate. I couldn't control it. And that's part of the reason it took me so long to speak up: I felt selfish, icky, and weird saying aloud that I'm struggling." 
•  Demi Lovato, “It's my mission to share this with the world and to let them know that there is life on the other side of those dark times that seem so hopeless and helpless. I want to show the world that there is life — surprising, wonderful and unexpected life after diagnosis." 
•  Cara Delevigne, “"It was realizing that I shouldn't be ashamed of feeling these things, and that I wasn't alone — learning that everyone goes through similar things... That being vulnerable is actually a strength not a weakness and showing your emotion and being honest about it is good." 

 The clinical syndrome of depression is a mood state including feelings of sadness, despair, anxiety, emptiness, discouragement, or hopelessness, or having no feelings.

 A major depressive episode is defined as including five or more of the following nine symptoms for at least two consecutive weeks, and at least one symptom must be either depressed mood or loss of interest or pleasure.

1.  Depressed mood most of the day
2.  Loss of interest or pleasure in most or all activities
3.  Insomnia or hypersomnia (sleeping too much)
4.  Significant weight loss or weight gain (e.g. 5 percent within a month) or decrease or increase in appetite nearly every day
5.  Psychomotor retardation or agitation nearly every day that is observable by others. (That means really slowing down or ramping up.)
6.  Fatigue or low energy
7.  Decreased ability to concentrate, think, or make decisions
8.  Thoughts of worthlessness or excessive or inappropriate guilt
9.  Recurrent thoughts of death or suicidal ideation, or a suicide attempt

      Sometimes it can be confusing to diagnose or untangle what is called major depression from a period of anxiety, loneliness or just good old aggravation that many of us may be experiencing presently. Providers trained in behavioral health are very good at helping people sort out what is going on -- that is making a correct diagnosis -- and then assisting them with making a plan for treatment. It must be noted that finding help for mental health issues in the U.S. can be notoriously difficult, even in urban and suburban areas. My only advice here is persevere. Sometimes you need to lean on a friend who works in the healthcare system who can, if necessary, pull some strings for you. I have done this for patients and friends many times.

    It should also be noted that depression often runs in families, and that depression can be caused or exacerbated by certain underlying medical illnesses and exacerbated by side effects of lots of medications. Depression usually strikes on its own, but in a minority of people it gets linked with episodes of manic behavior, and then is called bipolar disorder. The treatments for bipolar disorder are very different than the treatments for depression and I won’t get into that issue today. Depression can often be mixed in with substance use disorder, panic disorder/generalized anxiety and attention deficit hyperactivity disorder (ADHD. One of the gnarliest and scariest aspects of depression is that people with depression often cannot deal with or muster the energy to get help. That is why if you think you might have depression, or are living with someone who might have depression, or you have a friend who might have depression, it is incredibly important that you seek professional help.

     So, let’s move on to available treatments for depression. Traditionally, talk therapy or counseling has been a mainstay of treatment for depression. Since the advent of anti-depressant medications, many providers have shifted over to using medications instead of, or in addition to counseling. Many studies have shown that a combination of counseling and anti-depressant medications seems to provide the quickest and most durable improvement in symptoms for most patients. And, as I mentioned in a recent column, physical modalities such as exercise, yoga, dance, music and art can be very helpful with recovery.

     There are several classes of medications that can work against depression. It is impossible to know in advance which medications will work best for any individual, and a bit of trial and error is often involved. In general, it takes 2-4 weeks for an anti-depressant to kick in, though I have seen some people feel better in just a few days. Anti-depressants also have a lot of side effects, such as increased anxiety, worse sleeping, sexual dysfunction and nausea to name a few. If a patient needs to be on an anti-depressant, a well-trained behavioral health provider will be knowledgeable about how to switch around the meds to find the most effective medication with the fewest side effects. Typically, someone with major depression would stay on an anti-depressant for at least 6 months.

     People with depression suffer greatly, but the good news is almost everyone can be helped with good care. Please keep the signs of depression noted above tucked in your memory bank and remember to get help if the black cloud descends on you or someone you care about.

 Resources:

1.  The Noonday Demon – An Atlas of Depression, Andrew Solomon, 2001
2. An Unquiet Mind, Kay Redfield Jamison, 1995
3. Touched with Fire: Manic-Depressive Illness and the Artistic Temperament, Kay Redfield Jamison, 1996