Chapter 1: Depression Defined

THERESA: SAD AND AFRAID

Theresa's eyes filled with tears. Ever since she had been promoted at work, it seemed that she was too tired to think. She felt so out of her depth in the new position that a fear of being demoted by her boss gripped her daily. She felt that if she lost this job, she would never get another one this good.

In the evenings, she dragged herself home. Her husband, Jeff, had gotten into the habit of making dinner just for himself because Theresa never seemed to be hungry. Her lack of appetite was making her lose weight these days. At one time, her weight loss would have made her proud, but not now. Lately, she had no interest in anything. She used to enjoy her sexual relationship with Jeff, but not now. She was too tired. Yet no matter how tired she was, she still woke up around 3 A.M. every day and thought about her failures. She could not remember when she had last fell happy. And she was beginning to wonder if anything good would ever happen to her again.

ED: GROUCHY AND ACHY

Ed poured his nightly glass of wine. He had never been much of a drinker when his wife was alive, but he needed a glass to make himself sleep at night. While he drank, he watched television just to hear the sound of another voice. He did not think of himself as lonely, though. His life was not great, but it was not bad either. It was just ordinary.

If he wanted to talk to somebody, he could always call his son, Steve. Steve seemed worried about him now that he was living alone. He should be grateful for Steve's concern, but instead, he felt annoyed. There was something very irritating about Steve's constant questions and invitations to come over for dinner and suggestions that he join a senior citizens' club. In fact, just about everyone got on Ed's nerves more than they used to. It was easier to be alone.

Ed winced at the familiar pain in his stomach. Maybe the nightly wine was doing damage. His back had been bothering him a lot, too, but that was to be expected at his age. Maybe the stomachache was just another part of getting old.

MICHELLE: HAPPY, HAPPY, HAPPY

This was the best time of Michelle's life in every way. She had always wanted to write a novel, and now she was finally doing it. The ideas flowed into her mind so quickly that it was hard to get them all down on paper. She felt inspired; she knew her novel was brilliant. And now she had ideas for a screenplay, too. Finally, after all these years, she was realizing her creative potential.

Her sense of joy spilled into every area of her life. Nothing could put her in a bad mood. She had always been a little shy, but now she found it easy to approach strangers and start a conversation. The other day, she had overheard two neighbors talking about home repairs, and she had happily joined in. She had ended up doing most of the talking. She was more assertive sexually these days, too. She enjoyed letting men know she found them attractive.

Michelle had more energy than ever, no matter how hard she worked. After a couple of hours of sleep, she awoke completely refreshed. Michelle felt that she could accomplish anything. For once, she was so certain of success that she was willing to buy anything she wanted, no matter what the cost. She just charged it, whether she could afford it or not. She deserved good things. Nothing was beyond her.

Theresa, Ed, and Michelle are all behaving very differently, but they all have one thing in common. Theresa's unrelenting sadness and exhaustion, Ed's stomachache and irritability, and even Michelle's endless buoyancy and energy are all signs of one of the most common and destructive disorders in the US -- depression.

WHAT IS DEPRESSION?

Depression is a type of mental disorder that disturbs a person's mood. Human moods can be thought of as a kind of rainbow: each mood is distinct, yet each one blends into the next. The shades of this rainbow range from severe depression through mild depression, normal sadness, everyday moods, mild mania, and mania (euphoria mixed with behavior problems). Everyone moves through various shades of the rainbow; it is normal and appropriate to respond to such events as the loss of a job or a loved one with sad, gloomy feelings. When these feelings become inappropriate, extreme, and dysfunctional, however, they are seen as a mood disorder.

Because depression often goes untreated, doctors are not sure exactly how many people have the illness. They know, however, that it is far from rare. In fact, depression is so widespread that it is sometimes called the "common cold of mental illness."

The term depression is often used to describe feelings of deep sadness. Almost everyone experiences sadness at one time or another. But people with depressive illness -- sometimes called major depression, major depressive disorder, or clinical depression to distinguish it from ordinary sadness -- experience an overwhelming and debilitating despondency that is long lasting and typically interferes with a person's life at home, in the workplace, or in social situations. When healthy people feel dejected by everyday events -- a fight with a loved one, a rejection for a job promotion, a move from a familiar home -- they may say, "I feel depressed." But the feeling they call "depression" is distinct from the clinical disease of depression. Normal sadness, no matter how painful, usually goes away over time without special treatment. People who are sad can live their everyday lives despite their sorrow. By contrast, depressive illness does not fade so easily and can seriously interrupt a person's ability to think and act.

Left untreated, major depression can be dangerous. Suicidal thoughts are a common part of this illness. Although deeply depressed people rarely have the energy to commit suicide, they may be more likely to do so as their depression begins to subside. Untreated depression is the most common cause of suicide in the US.

In some people, periods of depression alternate with periods of extreme joy and dysfunctional behavior known as mania. Such people have a kind of depressive illness called bipolar disorder or manic depression, or manic-depressive illness. This illness can make you hyperactive, irritable, and excessively self-confident. In addition, it can destroy your normal judgment and cause reckless behavior. Michelle's feelings of invincibility and wild spending habits, for example, are all symptoms of her mania.

Cyclothymia, also called cyclothymic disorder, is a milder but more lasting form of bipolar depression. People with cyclothymia have moods that swing between hypomania (a mild form of mania) and mild depression.

Like major depression, bipolar depression can be dangerous. During the depressed phase of your illness, you may be haunted by thoughts of suicide. During the manic phase of your illness, your good judgment may evaporate and you may not be able to see the harm of your actions. You may incur huge credit card debts, for example, or become sexually promiscuous. In some cases, people with mania lose touch with reality.

Milder, less common forms of depression include dysthymia, also called dysthymic disorder or depressive neurosis, and minor depression, also called minor depressive disorder. Recurrent brief depressive disorder feels like major depression but lasts for only a brief time. Postpartum depression is a depressive illness that develops in new mothers about 1 week to 6 months after the birth of their babies. Premenstrual dysphoric disorder is a cyclic illness that affects 3 percent to 5 percent of menstruating women. Women with this illness feel extremely depressed and irritable for a week or two before menstruation each month. Seasonal affective disorder (SAD) is a type of depression that occurs only at certain times of the year. People with this illness typically feel lethargic and depressed during winter months, yet their moods are normal during the summer months. Atypical depression has a mix of depressive symptoms that do not fit in perfectly with any of the existing categories.

In all its guises, depression distorts the way people view themselves, others, and the world. Theresa's thoughts are warped by self-loathing. Ed's irritability is damaging his relationships with other people. While Michelle's illness may seem to have positive aspects, it is clouding her judgment and making her act recklessly. In each of these cases, depressive illness is preventing people from leading their everyday lives.

No matter how their symptoms may vary, people with depressive illness find it affects almost every aspect of their lives, from how well they concentrate at work to how deeply they sleep at night. Eventually, it can make ordinary life impossible. But depression, in all its forms, can be treated. Major depression is one of the most treatable illnesses. Bipolar depression has no cure but can be controlled with medication. Other types of depression are also treatable.

The different types of depressive illness are discussed more fully in Chapter 2. Treatments are discussed in Chapters 5 and 6.

Am I Depressed or Just Blue?

If you are coping with a major loss, such as the death of your spouse or partner, you will experience some symptoms of depression. For example, you may find it hard to fall asleep, you may have no appetite for food, and you may have difficulty concentrating during the day. During a period of mourning after a major loss, such symptoms of depression are normal. Chances are you are enduring normal grief which, though difficult, is healthy.

Normal grief tends to go through stages, during which you react to your loss by first denying it, then coming to terms with it, and eventually accepting it. Immediately after the death of a loved one, for example, you may react with tears or pretend that he or she is still alive. You make funeral arrangements but your actions feel unreal, as if you were watching a movie. You cannot believe this has happened to you. You may feel completely numb.

Later, these feelings change as you acknowledge the reality of your loss. This is when you may experience sleeplessness, fatigue, lack of appetite, or other symptoms of depression. You may also feel guilty, disorganized, bewildered, and despairing. Activities you used to enjoy have no appeal. You may avoid family and friends. The memory of your loved one may preoccupy you, and you may yearn to see him or her just one more time. Perhaps you fantasize about dying and joining your loved one. (Thoughts of suicide are not usually part of the normal grieving process; see "Do I Need Help?" [pages 116 through 119] in Chapter 5, "Getting Help for Depression.") Slowly, however, your feelings change as you come to accept your loss. You still miss the person who died, but you regain your interest in other people. You care about whether your clothes are clean or your hair is tidy. A tasty meal or a sunny day gives you pleasure again.

At some point during your mourning, your grief can begin to make a great impact on your life. Sometimes, normal grief motivates people to change their lives. If your loved one was murdered, for example, you might become active in a group that lobbies for changes in the sentencing of convicted murderers. You might start to devote much of your spare time to the work or favorite charity of the person who died, or even make your loved one's work your full-time occupation.

Other people may react to a loss, particularly a loss of health or mobility after a serious illness, by becoming demoralized. People in this situation can experience some symptoms of depression, including low self-esteem, feelings of hopelessness, or a heightened sense that life is out of control. People with cancer, heart disease, or serious burns often experience such loss of spirit. The person's spirit generally returns when self-esteem improves during rehabilitation therapy.

Of course, many of us who have not endured a great loss still feel blue from time to time. Perhaps you lost your car keys on Monday, were denied a pay raise on Tuesday, and had to cope with blocked drains on Wednesday. Now you feel as if nothing will ever go right. Or maybe you have just returned to a difficult job after a delightful vacation and you now think that you have absolutely nothing to look forward to. You may feel pessimistic and grouchy for no very good reason. These moods are normal, provided you can continue to lead your life.

If you feel low in spirit but continue to do your work well and maintain your relationships with family and friends, you are not clinically depressed. Sadness and anxiety are often healthy reactions to losses, large or small. For at least 2 months after your loss, these symptoms are considered normal. But healthy grief that persists and remains severe for a long time after a loss can slowly deepen into clinical depression. If you are clinically depressed, you will not function normally. Your symptoms will be longer lasting, more extreme, and less likely to improve without treatment, and they will prevent you from behaving normally at work or in social situations.

An important difference between normal sadness and clinical depression is the effect your condition has on your self-esteem. People with clinical depression contend with constant negative thoughts about themselves, their lives, and their futures. Hopelessness paralyzes them. They may think that nothing ever works for them, that nothing ever will. They feet stuck, unable to act, and unable to relate to other people. People experiencing normal sadness or a negative mood may brood about their situation, but basically they are the people they have always been. Despite everything, they feel active and alive.

For example, a healthy person just fired from a job may think, "I feel terrible about losing that job. The money was good and I liked the work. Plus, I was good at it. I did not deserve to be fired." A clinically depressed person, by contrast, may think, "How can I survive without my job? I know I will never get another. I am a terrible person and a total loser." The healthy person's outlook is an honest and realistic assessment of the situation, while the depressed person's outlook is overly negative and unrealistic and may lead to an inability to take action.

FACTS AND FIGURES ABOUT DEPRESSION

Research has shown that in a given year, at least 17.5 million American adults -- 1 in 10 -- will experience depression and that there is a depressed person in an estimated 1 in 5 families.

Some forms of depression are more common than others. Major depression is likely to affect about 15 percent of Americans at least once in their lifetimes. Bipolar disorder is thought to occur in at least 1.2 percent of the population, or more than 3 million people. Milder versions of these illnesses may affect a further 2 percent to 5 percent of Americans. Particular groups of people are also more likely than others to develop depressive illness. Women, for example, experience depression at roughly twice the rate that men do. Depression is found in all age groups but occurs most frequently in middle-aged adults.

Depressive illness may be growing more prevalent in the US. Research shows that more people are now developing depression at an earlier age. For example, of the generation born between 1940 and 1959, about 10 percent may have experienced an episode of depression by the age of 25. Of the generation born before 1940, only 2.5 percent experienced depression by age 25. Researchers are uncertain how to interpret these statistics. Doctors may be better at diagnosing depression in young people today than they were in the past, or older people may not accurately remember when they first experienced depression.

Depression is costly, in both economic and human terms. The economic cost of depression ranges from $15 billion to $35 billion a year in lost time and productivity, employee turnover, and medical care. We have no way to measure its human cost. Untreated, the disease damages self-esteem, promotes substance abuse, disrupts relationships and careers, and sometimes causes disability or even death.

Many depressed people today fail to recognize depression in themselves. Indeed, certain symptoms of depression may even prevent a person from seeking help. If you experience the feelings of self-loathing common in depression, you may blame yourself for your low feelings. If you experience fatigue also, which is common, seeing a doctor may seem too exhausting to attempt. If you feel the unwarranted invincibility of mania, you may reject even the possibility of illness.

But even among those who recognize their illness, many decline to get help. Doctors estimate that two thirds of people who have depression fail to seek treatment. The reasons for this vary, but many people do not seek treatment simply because the illness is misunderstood. It may be seen as a sign of weakness. However, depressive illness is no more a personal failing than is heart disease, high blood pressure, or any other medical condition. It cannot be shaken off at will. Sometimes when people have the blues over some temporary setback or disappointment, it helps for them to keep busy or make an effort to pull out of their momentary feeling. But this is not true for depression. Without medical care, depression can last for weeks, months, or years.

Yet depression is a highly treatable illness. Doctors can remove or reduce all the symptoms of depression in more than 80 percent of their patients. But the longer the illness goes undetected and untreated, the more difficult it becomes to treat. Severe, untreated depression can result in suicide. People whose depression is severe enough to require hospitalization have a suicide rate as high as 15 percent.

Such statistics may seem daunting. But doctors today know far more about depression -- its possible causes and effective treatments -- than they knew even 20 years ago.

WHO IS AT RISK FOR DEPRESSION?

To some extent, we all run the risk of depressive illness. Depression has been diagnosed in all kinds of people: rich and poor, young and old, married and single. Stressful events come along in every life, and if these events are sufficiently severe and numerous, they may trigger depressive illness. We are also all vulnerable to physical ailments and have the potential to develop a disorder that later gives rise to depression. While no one is entirely immune to depressive illness, the most common forms -- major depression and bipolar depression -- do affect some groups of people more than others.

Gender Factors

Women are diagnosed and treated for major depression more often than men. In the US, a woman is about twice as likely as a man to be diagnosed with depression. Researchers have found that depression is equally common among male and female children, but during adolescence, girls start to show more depression than boys. This vulnerability continues throughout a woman's adult life. Even in old age, more women than men have depressive illness. In the US, about 20 percent to 25 percent of women will become seriously depressed at least once in their lives. Of men, about 12 percent will do so.

Doctors do not fully understand why they treat more depressed women than men, but they have several theories. One is that women are more prone to depression because they have more stress than do men. Women today have to cope with conflicting roles, with demanding schedules at work and at home. Some experts believe the traits encouraged in girls as they grow up, such as a willingness to please others rather than themselves, may later make them prone to depression.

Another explanation is that it is not that depression is actually more widespread among women but that women are more likely to seek treatment. Women may be willing to acknowledge the emotional symptoms of depression, such as feeling sad, lonely, or hopeless. According to this theory, men are less inclined to admit to such feelings. Also, doctors who diagnose depression may be biased and more likely to look for it in women than in men. Some researchers suspect that such a bias may account for the fact that women make up about 60 percent of medical patients yet receive about 75 percent of all prescriptions for mood-altering drugs.

Some theories suggest that men may try to stifle their depression with alcohol or other substances instead of seeking medical help. The depression may be masked -- that is, seen as the result of the alcohol or drug dependency rather than as a separate disorder. As a result, men may be less likely to be treated for depression.

The idea that depressive illness is overlooked in men is supported by research on depression among Amish people in Pennsylvania. The Amish people are members of a Protestant religion that requires personal simplicity and withdrawal from the modern world. Amish farming communities typically are self-reliant and tightly knit, and large families and cooperation among neighbors are common. Studies have shown that depression is equally common among Amish men and women. One possible explanation of this is that Amish men cannot mask their depression with drugs or alcohol because such substances are strictly forbidden by their religion. Also, the close ties among Amish people may ensure that any unusual behavior is promptly noted and treated.

Another theory is that women are more vulnerable to depression because their bodies experience a constant ebb and flow of hormones. Hormones are chemicals produced by certain organs and glands in the body that control many of the body's processes, including growth, metabolism, and sexual development. Hormonal levels shift routinely during a woman's monthly menstrual cycle. In some women, there may be a link between depression and these cyclic changes. Times of particularly great hormonal change in women include pregnancy, the time immediately after giving birth, and menopause, the period of a woman's life when her menstrual cycles become increasingly infrequent and then stop. For a few women, some of these milestones are marked by depressive illness.

Studies disagree over the relationship between pregnancy and depression. It appears, however, that pregnant women who are especially prone to depression are those who have unhappy marriages, who do not want a baby, and who have a history of depression or relatives with depression. Many women experience shortlived "blues" in the first few days after giving birth. Few women go on to develop full-blown depressive illness during the period after childbirth.

Menopause was once thought to be a time of depression. In fact, doctors regarded such depression as a unique disorder that they called involutional melancholia. Today, we know that it is not a unique disorder and that in general, women do not always develop it during menopause. Women who do develop it at that time typically have had a history of depressive illness.

Among women, rates of major depression are highest among the unhappily married, separated, and divorced, and lowest among the happily married. And though depression is cross-cultural, it appears that doctors in the US diagnose depression less frequently in African American women than in white women and more frequently in Hispanic women. One possible explanation of this, researchers believe, is that African American women are more likely to complain of the physical symptoms of depression than of the mood changes that go with it. This may be based on cultural issues about seeking out psychiatric help.

In contrast to major depression, bipolar disorder affects men and women equally. Why depression is found overwhelmingly in women, while mania is not, is unclear. But it may be that mania is simply more likely to be noticed than depression because of its striking symptoms. Also, it could be that depression is simply overlooked in men.

Creativity as a Risk Factor

Artists and writers, as a group are more likely to experience depression than other groups. Artists believed to have had depressive illness include writers Ernest Hemingway, Leo Tolstoy, and William Styron; poets Sylvia Plath, Anne Sexton, and Walt Whitman; and painters Georgia O'Keeffe, Vincent Van Gogh, and Jackson Pollock. Some scientific studies claim to confirm a link between artistic achievement and depressive illness. For example, one study compared 30 members of the University of Iowa Writers Workshop with a group of nonwriters. Depressive illness was far more common among the writers -- about 80 percent had either depression or mania, compared with 30 percent of the nonwriters. A separate study of leading British writers found that more than one third of the participants had been treated for depressive illness. These studies are far from conclusive, however, and much research must be done to confirm any link between depression and creativity.

If creativity and depressive illness are in fact linked, the exact connection between the two is unclear. It is less likely that creative work will be produced while an artist is experiencing depression, mania, or hypomania. Researchers found that many artists were unable to work while depressed and that artists produced poor work during mania. In addition, the artists found it hard to concentrate and were easily distracted during hypomania.

Age Factors

Depression and mania can affect people at any age, but symptoms are more likely to appear for the first time at certain stages of life. For example, you are most likely to experience your first episode of mania while in your teens or twenties. Depression also generally emerges for the first time in adults. In about half of depressed people, the illness first occurs between the ages of 20 and 50.

Although depression typically emerges for the first time in young people, older people as a group seem particularly susceptible. Estimates of how many older people have depressive illness vary widely. According to one estimate, about 15 percent of people over 65 years of age have some symptoms. Their symptoms may be mistakenly interpreted as due to physical problems instead of depression. People living in nursing homes seem to be especially at risk.

There are many possible reasons for this high rate of depression among older people. Older people typically have gone through a number of losses, such as diminished health, the death of a spouse or partner or friends, or lowered income after retirement. In addition, depression can be part of physical illnesses that are more common in this age group, such as cardiovascular disease. Also, depression is sometimes a side effect of prescription drugs, which are used more frequently by older people -- those over 65 take an average of seven or more medications each day. Depression may be a side effect of one such medication or a combination of several medications.

Other Factors

Your chances of getting depression or mania increase if you have had the illness before. Estimates vary, but about half of people who have depression once develop the illness again. In bipolar disorder, most people who have had one episode will experience a second.

You are also more likely to develop depressive illness if you have a relative who has had a depressive illness. This is especially true of bipolar depression. According to some scientific studies, immediate family members -- parents, siblings, or children -- of people with bipolar depression are 8 to 18 times more likely than the close relatives of healthy people to develop the illness. In addition, having a close family member with bipolar depression may make you more vulnerable to major depression. According to some studies, immediate family members of people with bipolar depression are 2 to 10 times more likely to have major depression than are the close relatives of healthy people. Likewise, if you have a close relative with major depression, you may be twice as likely to develop bipolar or major depression than other people.

Your ethnic background does not seem to affect your chances of developing depression or mania. It may affect your chances of receiving the proper diagnosis and treatment, however. Studies have shown that doctors are less likely to recognize mood disorders in people from an ethnic group that is different culturally from their own. A doctor of a particular ethnic group may perceive behavior that is accepted among people of another ethnic group as eccentric or abnormal.

In men and women, depressive illness is more common in people who are divorced, separated, or have no close relationships. Depressive illness puts great strain on relationships, and people who are alone often lack an emotional support system. Also, bipolar depression usually first emerges in youth, and people with this illness may have fewer opportunities to date or get married. Depression also seems to be common in widows and widowers. One study, for example, found signs of depression in about one sixth of widows and widowers 1 year after the death of a spouse or partner.

Certain personality traits may make you more vulnerable to depression. If you tend to criticize yourself, take a pessimistic approach toward life, or depend unduly on other people, you may be more prone to depression than happy-go-lucky types. A person who is withdrawn and reluctant to reach out to other people may also be at risk. By themselves, these traits certainly do not cause depression. But suppose, for example, you have a genetic predisposition to depression and have recently experienced several losses. Your inability to reach out to other people in this situation may put you at a higher risk for depression than a person who can easily ask for help.

Certain losses may make depression more likely later in life. The loss of a parent or significant loved one before the age of 11 may make you more prone to depression as an adult. People who have gone through other catastrophic losses, survived disasters, or participated in combat during a war are also at risk. Losses and other painful experiences themselves probably do not cause the depression, but they may result in a lifelong vulnerability or accentuate a genetic vulnerability.

Depression and mania can affect people in all social classes. Depression appears to be equally common among the rich and the poor. Bipolar disorder is most often diagnosed in people of comfortable means, perhaps because they have greater access to health care. Bipolar disorder is also more common among those without a college degree than among college graduates. This may be because the illness typically develops at an early age and is likely to interfere with a person's studies.

Although some people seem more prone to depressive illness than others do, no one is predestined to become ill. Many children of depressed people, for example, never develop the illness despite being at risk. Knowing that you are at risk for developing depressive illness may motivate you to learn more about the illness, to be alert for its warning signs, and to take steps to lessen your vulnerability -- by avoiding excessive amounts of stress, for example. Far from making depression inevitable, knowing the risks can help you beat it.

Copyright © 1998 by American Medical Association