Winston Churchill called it his “black dog.” Mystics called it the “dark night of the soul.” By whatever name, depression has been a scourge for mankind since at least the time of King Saul, who may have suffered from this illness himself. Abraham Lincoln-who struggled with depression most of his adult life-once wrote (after a break in his engagement to Mary Todd), “If what I feel were equally distributed to the whole human family, there would not be one cheerful face on the earth.”

Depression is a common disorder. According to DSM-IV, the lifetime prevalence of a major depressive disorder for women is from 10% to 25% and from 5% to 12% for men. Major depression may begin at any age, but usually has its onset in the late 20s or 30s. Depression in its various forms costs the U.S. economy over $40 billion annually. But this figure can never express the emotional cost to those who suffer with severe depression, and to their loved ones. What does depression look like? What questions should a family member ask of a loved one who seems depressed? What treatments and resources are available for this condition? And how do caregivers cope with seriously depressed family members? These questions are the focus of the present article.

Portrait of Pain

Let’s consider the case of “Anne,” a 35-year-old stockbroker. At age 30, soon after being turned down for a big promotion, Anne experienced her first episode of major depression. At first, she tried to cover over her feelings, putting on a “happy face” in front of her husband, Ed, and their two children. But soon, the masquerade became too much to bear. Anne began to have trouble with her sleep and appetite. She would awaken at 3 a.m. and be unable to fall back asleep. Her appetite practically disappeared, and she lost nearly 30 pounds over the course of three months. Anne felt drained of energy and motivation, and found that the things in life that used to give her pleasure-listening to music, gardening, and reading-no longer pleased her. Her sexual drive, as she put it, “went to absolute zero,” and she was unable to concentrate on anything for more than a few minutes.

Ed couldn’t understand what was happening, and found himself irritated with Anne. This only compounded his wife’s misery. Anne began to feel guilty, worthless, and “like not going on with life.” Even when something good happened-like the kids doing well in school-Anne’s mood remained “in the pits.”

One night, when Ed was staying late at work, Anne decided to take an overdose of sleeping pills. Fortunately, she wasn’t able to keep the pills down, and when Ed returned, Anne tearfully described what had happened. Ed contacted the family doctor immediately, and Anne was hospitalized.

Symptoms of Depression

While the symptoms of major depression vary somewhat from person to person, Anne’s case is fairly typical. Everyone feels a little “down in the dumps” now and then. But if you or a family member has one or more of the following for more than a few days, you or your loved one should be evaluated to rule out major depression:

Loss of energy or chronic fatigue
Feelings of “emptiness”
Loss of pleasure and interest in nearly everything
Disturbance in sleep, appetite or weight (loss or gain)
Recurring thoughts of dying, death or suicide
Feelings of hopelessness and helplessness
Feelings of worthlessness or intense guilt
Poor concentration or memory loss
Physical symptoms (such as headache, stomachache) that are not explained by medical illness

Some people have atypical forms of depression. They may experience high degrees of anxiety or phobic symptoms, or experience numerous aches and pains that have repeatedly turned up nothing on medical examinations. Or, they may report feeling angry and irritable nearly all the time. Some people don’t use the word depressed to describe how they feel, and yet, they have many of the symptoms Anne experienced. Some elderly individuals, for example, will report being “tired, achy and weak,” and deny being depressed-and yet, depression is really the root of the problem. Some depressed children or adolescents may show aggressive behavior, poor school performance or drug abuse instead of (or in addition to) the usual symptoms of depression. When in doubt, consult your family physician.

Some people have a form of depression that alternates with very “high” periods, in which the person feels excessively happy (euphoric), overly-energized or “speeded up.” Often, during these high periods, the person does not need much sleep, takes on dozens of chores at once and shows very rapid, pressured speech. Sometimes, during these upswings in mood or energy, the person can become very irritable or even aggressive. Their behavior may be bizarre; for example, they may spend thousands of dollars in a matter of hours, or drive half-way across the country. Sometimes they express beliefs that are very unusual for them, such as “I’m the greatest genius that ever lived” or “I have powers nobody else on earth possesses!” This constellation of symptoms is often part of a manic episode, and indicates that the individual suffers from bipolar (manic-depressive) disorder. Often, after a manic episode, the bipolar individual will “crash”-and wind up looking and feeling a lot like Anne.

Finally, major depression may be mimicked by a variety of medical and neurological disorders, ranging from B-vitamin deficiencies to thyroid gland problems to early Alzheimer’s disease. This is why severe depression should always be evaluated first by a physician.

Helping a Depressed Family Member

What should you do if you think a friend, family member or loved one might be depressed? First, remember that major depression is not a character flaw, nor is it just unhappiness. It is a disease with biological, psychological and social causes-no different in its effects than other serious medical diseases, such as epilepsy, asthma, or diabetes. The severely depressed person cannot just “pick himself up by the bootstraps” by an act of will. The individual does not need a “pep talk,” a sermon, or a “change of scenery,” but rather compassionate understanding, and then professional help.

How do you decide if a loved one is depressed? In addition to watching out for the symptoms described above, you can ask a few simple questions, such as: “Joe, I’m a little worried about you. You don’t seem yourself lately. How are you feeling?” Depending on the response, you can ask more pointed questions such as, “Are you feeling really down? How bad has this feeling gotten lately? Has it gotten to the point where you are thinking about not going on with life?”

If the person answers “yes” to this last question, you need to assess how urgent the situation is. Don’t be afraid of “putting the idea” of suicide into someone’s head. Almost always, the truly suicidal person is relieved that someone has finally taken him or her seriously. If the person has actual suicidal plans-for example, taking an overdose of pills or buying a gun-they need professional help right away. Calling your family doctor is one good option at that point. If your family member is severely suicidal and refuses to get help, you may need to call 911 or your local psychiatric emergency room to get help.

Treatments for Depression

Fortunately, major depression and bipolar disorder are very treatable illnesses. With the proper care, the vast majority of sufferers can feel much better within a matter of weeks or months. Treatment consists of either talking therapy, medication or some combination of the two. While many types of psychotherapy may be helpful for major depression, the best-researched types are called cognitive-behavioral therapy (CBT) and interpersonal therapy (IPT). Therapy may be done individually, in a group setting or in a combined format. Sometimes family or marital counseling is helpful, too.

There are many types of antidepressants available today, and all prescribed antidepressants are roughly equal in effectiveness. The so-called SSRIs (selective serotonin reuptake inhibitors) make up the most widely prescribed group of antidepressants. These all act mainly on a chemical in the brain called serotonin. Fluoxetine (Prozac), Sertraline (Zoloft), Paroxetine (Paxil) and Citalopram HBr (Celexa) are commonly prescribed SSRIs. These medications are both safe and effective for the vast majority of patients with major depression. They are not necessarily appropriate for all patients with bipolar disorder, since they sometimes can cause mood swings. Common side effects with the SSRIs include mild gastrointestinal complaints, headache, jitteriness (which is usually temporary) and sometimes sexual problems. Most of these can be addressed with dosage reduction or other medical remedies. In some cases, a different type of antidepressant, such as Bupropion (Wellbutrin) or mirtazapine (Remeron) may be required. For most patients, the benefits of medication far outweigh the relatively minor side effects.

In very severe cases of depression-especially when accompanied by delusions or hallucinations-a form of treatment called electroconvulsive therapy (ECT) is needed. Contrary to some popular myths, ECT is both safe and effective for severe depression, and does not cause brain damage, although it may have short-term effects on memory.

Who Cares for the Caregiver?

Sometimes, even with the best professional care, the person with depression takes many months to recover. And, unfortunately, at least 50% of individuals with major depression have several bouts of the illness over the course of a lifetime. Cases of treatment-resistant or chronic depression can take their toll on family, friends and other caregivers. Family caregivers may feel “burned out,” frustrated or even depressed themselves. They may feel angry at their depressed loved one, and then feel guilty about being angry. While such feelings are common, they can be very distressing, and the caregiver may not know where to turn for help, support or advice.

The Massachusetts Medical Society is developing some tips for caregivers, which appear in a modified format below:

 
• Be gentle with yourself-you are probably doing your best to cope.  
• Remind yourself that you are a caregiver, not a magician.  
• Find a personal “space” for yourself where you can refresh your energy during a difficult day.  
• Acknowledge that at times you feel helpless, and that this is nothing to be ashamed of.  
• Try to find new and interesting things to add to your personal life-a social club, for example.  
• Learn to tell the difference between assertiveness that relieves your stress, and complaining that worsens it.  
• Each day, try to focus on something good that happened or something positive that you accomplished.  
• Use a buddy system whenever possible-get help from friends and other family members, and give them support in turn.  
• Give yourself a break now and then by doing something you really enjoy.  
• Get counseling from your family doctor or a mental health professional if you are feeling burned out or depressed yourself.

Finally, here are some organizations and resources that can be very helpful for those suffering with depression, as well as for family members and caregivers. The National Depressive and Manic-Depressive Association can be especially helpful.

by Ronald Pies, M.D.
Dr. Pies is clinical professor of psychiatry at Tufts University School of Medicine and a lecturer on psychiatry at Harvard Medical School. His most recent book, Ethics of the Sages, is available from Jason Aronson Inc.