Encounters With Depression

Depression, like love, is probably one of the most misunderstood words of the English language. It has been a mystery for lay people as well as professionals for centuries. It means different things to different people.When lay people talk about depression they refer to a sadness that most people feel for short periods of time off and on when they are disappointed in something or someone in their lives. When someone arrives late at work and is asked by his colleagues, "How are you feeling?” he might say, "I am depressed."If asked further, "How come?” he might answer something like:

"My car broke down."
"My son is sick with the flu."
"I got a speeding ticket on my way to work."
"My mother-in-law is visiting us for the weekend."

Such depression lasts for a few hours or a few days and the person recovers from it completely. Such sadness does not interfere with the quality of life and does not need any professional intervention.

When mental health professionals talk about depression, they mean a human condition that is not only far more serious than ordinary sadness but also lasts for months and sometimes years, affects the quality of life significantly and needs professional help for recovery. Some people feel so desperate that they want to commit suicide and are admitted to hospital for intensive observation and treatment.When we study the literature on depression, we become aware that the terminology and classification has changed over the centuries and even in the last few decades of this century. There was a time when the term melancholy was used frequently, then a time came when the terms neurotic and psychotic, exogenous and endogenous, involutional and reactive became popular and in the last couple of decades the term dysthymia is more in vogue. Without going into the academic details one can understand depression by classifying it into three broad categories.

The first type of depression is an Acute Reaction to a loss of something or someone very dear to us. Loss of a job or a significant relationship is common reasons precipitant to a depressive reaction. Such a depression can easily last for a few months and needs support from family, friends, and therapists to recover. If that depression is precipitated by the death of a dear one we call it a grief reaction. After the death, the grieving people need to readjust not only their thinking but in most cases also their lifestyles. Depression can also be a reaction to a loss of a role. Many mothers, who enjoy their mothering role tremendously, when they get to a stage of life when their last child goes to school or leaves home or gets married and their mothering role is not needed, become depressed.

Sometimes the loss is quite subtle. I remember a nurse who was quite happy about her promotion to head nurse but after a few months when she gradually realized that she had lost the camaraderie of her colleagues who now perceived her as their boss rather than a friend, she became depressed.In some cases people get depressed when they lose their meaning or faith in life. After the fall of the U.S.S.R. some communists felt so depressed they committed suicide.

The second type of depression is chronic unhappiness that is the result of a very frustrating and dysfunctional lifestyle. If people are working at a job in which they feel existentially suffocated or they are a part of a relationship in which their needs are not met on a regular basis, they become chronically unhappy and feel depressed. Such depression is called dysthymia.

The third type of depression, which is the most serious one, is part of an illness called Affective Disorder or Manic-Depressive Illness. Such an illness is called unipolar if the individual has only episodes of depression; but if they also have episodes of mania we call if bipolar. People suffering from unipolar or bipolar illness have biochemical changes in their brains and need treatment with medications to control the symptoms. If the condition becomes worse or difficult to treat as an outpatient, the person needs hospitalization.

To understand depression it is important to know that contributing factors that make people vulnerable to experience episodes of depression. Since depression is a psychological reaction to a loss, the more significant the loss, the more impact it has on the person. Those people who have a tendency to "put all their eggs in one basket", whether it is a job, a romance, their family or any other aspect of their lives, are more vulnerable than those people who have their emotional investments in many things and people. If they lose one thing or person there are others to offer support and satisfaction. Those people who are emotionally dependent on their parent or a spouse or a best friend usually fall apart when they lose that relationship as they cannot function without that person in their lives.

Such people are prone to suffer from grief reaction.Those people who suffer from dysthymia usually have developed learned helplessness. They feel so overwhelmed by their day-to-day problems that they become emotionally paralysed and are unable to break the negative cycle. Many people stay in unsatisfactory jobs because they are afraid that they might not find another job and their families might starve to death. There are others who stay in unhappy, controlling and even abusive marriages not out of love but out of obligation or guilt. For many spouses who are afraid of loneliness, a bad relationship is better than no relationship. Many women, especially those who have small children and don’t have a profession, feel very vulnerable financially and emotionally. They feel that if they left the marriage their children would suffer. For the sake of the children they sacrifice their youth and remain depressed for years. Many such mothers feel chronically tired and exhausted and drained looking after the family’s needs but ignoring their own. When they do things for themselves they feel guilty. They have not learnt to look after themselves.It is also interesting to note that a large number of people who suffer from depression have perfectionistic and idealistic personalities. They have high expectations from their friends, spouse, relatives and even from themselves. That is why they are easily disappointed and get depressed. They do not realize that their expectations from life are unrealistic. Many of them have grown up in families where their parents had high expectations from them and they felt loved not for whom they were, but rather for how well they performed. That is why children from upper middle class and professional families, where every child is expected to stand first in the class, are more prone to depression. And even among siblings, it is usually the first-born who is prone to adopt that philosophy and lifestyle. If they stand second in the class of thirty students, rather than being praised and rewarded, they are scolded for not standing first. Later on many of those students internalize the expectations of their parents and feel disappointed in themselves if they are not high achievers.

It becomes difficult for them to enjoy the process, the journey. They are generally preoccupied with the goals and destination.Many men who stay in unsatisfactory jobs and many women who stay in unhappy marriages also suffer from poor self-esteem. Unconsciously they convince themselves that they don’t deserve any better. Some of them also have unresolved guilt and unconsciously punish themselves. One woman told me that she started putting on weight consciously because she wanted to become unattractive. She wanted her husband to leave her, as she did not have the courage to leave him. She had convinced herself that she was unlovable.

As far as manic-depressive illness is concerned, there is enough evidence that the illness runs in families. Bipolar illness appears to have stronger genetic loading then uni-polar. Children born to manic-depressive parents are vulnerable to have biochemical changes and depletion of nor-adrenaline, dopamine or serotonin in the synapses of their brains when they face crises. Such biochemical changes produce physical symptoms generally known as vegetative symptoms, which include:

* loss of appetite and weight,
* lack of sleep,
* early morning wakening,
* constipation,
* amenorrhea, no menses, in women,
* feeling worse in the morning,
* lack of energy and motivation.

Such symptoms differentiate biochemical depression from psychological depression, which is a reaction to environmental factors. Biochemical depression can get so bad that patients might have disturbances in thinking, concentrating and motor functions, which is why it is called psycho-motor retardation.People suffering from such major depression sometimes have intense guilt about events from the past that most people would consider insignificant. One lady in her late sixties who suffered from major depression became preoccupied with her first date when she was sixteen and felt guilty about kissing her boyfriend at the end of the evening.People who suffer from bipolar illness also have manic episodes alongside depressive episodes. The symptoms of a manic episode are opposite to a depressive episode. Many patients

* feel lots of energy
* think fast
* feel extremely happy for no obvious reason and act bizarre.

Some people in manic episodes don’t sleep for days, do household work at odd hours of the night and sometimes spend thousands of dollars within a few days. In many such cases patients need to be hospitalized.

Treatment of depression depends upon the diagnosis and the understanding of the underlying dynamics. Those patients who suffer from manic-depressive illness usually respond well to antidepressant medications and Lithium in an acute episode and education and psychotherapy later on. People suffering from grief reaction usually do very well with a few months of supportive therapy while those suffering from dysthymia generally need long term psychotherapy in which personality factors need to be addressed. In therapy patients are made aware of their perfectionistic tendencies and high expectations. When they learn in therapy how to deal with losses and disappointments, then they can prevent future depressive episodes. When they improve their self-esteem and self worth and establish a support network, then they are more equipped to cope with disappointments in their lives. Since depression affects the whole family it is important for the family to receive education and support. In the last few decades there have been Manic-Depressive Associations in many communities that offer support to the friends and families of the people suffering from depression.There has been gradual awareness in the public that depressions don’t just affect individuals - they affect families and communities, and joint efforts are needed to control and prevent them. Public education through newspapers, magazines and television programs have also played a significant role in increasing social consciousness. More and more people are receiving professional help and are convinced that there is a light at the end of the dark tunnel.