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

December 09, 1990|MIRIAM SHUCHMAN MD and MICHAEL S. WILKES MD | 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.

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.

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.

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