Undoing Depression: What Therapy Doesn't Teach You and Medication Can't Give You

First Chapter

Undoing Depression

Little, Brown and Company

Part 1

What We Know About Depression

1

Understanding Depression

WE ARE LIVING in an epidemic of depression. Every indication suggests that more people are depressed, more of the time, more severely, and starting earlier in their lives, than ever before. Depression is not going to go away no matter how much we ignore it, scorn it, or neglect it. We need to attend to it as a major public health problem. But that’s difficult to do because the idea of depression frightens us all — we think of a descent into madness — and thus we avoid the subject. We have a natural wish to forget about depression, to hope that we are immune. Can you make yourself remember the sensation of pain? Most people react to the question with a cringe but really can’t describe pain or evoke the sensation in their memory. We repress it, push it away, so that most of the time we don’t think about it and we can get on with life. But when we hear the dentist’s drill, we suddenly remember exactly what it’s going to feel like. We do the same mental trick with depression. We’ve all felt it, but we believe we have to shut out the memory. We want to think of depression as something that happens to somebody else.

But it strikes closer to home now, because the incidence is increasing. For each generation born since 1900, the age of onset of depression is younger and younger, and the lifetime risk has increased. According to the most official, conservative estimates, approximately 6.7 percent of Americans will experience an episode of major depression in their lifetimes. When you add in the so-called milder forms of depression, I believe the rate goes up well past 25 percent. Every fourth person you meet is likely to have a serious encounter with depression at some point in their lives. And every fifth person is depressed right now: researchers estimate that almost 20 percent of the population meet the criteria for some form of depression at any given time — and that does not mean people who are temporarily feeling the blues and will be better next week, but people who are having real difficulty functioning in life.

This epidemic is not merely a result of growing awareness of depression, but a true growth in hard numbers. Nor is it only a phenomenon of American, or even Western, culture. A recent study comparing incidence of depression in Taiwan, Puerto Rico, and Lebanon, among other countries, found that for each successive generation, depression was likely to begin at earlier ages, and that over the course of a lifetime, the risk of depression kept increasing. Of all people with major depression, 15 percent will end their lives by suicide.

Clinical depression is a serious, often fatal illness that is so common it’s hard to recognize. But health economists consider it just as disabling as blindness or paraplegia. In terms of overall economic burden to our society, depression is the second most costly disease there is. This surprising news comes from the World Bank and World Health Organization, which measured the lost years of healthy life due to disease. The cost, in terms of direct treatment, unnecessary medical care, lost productivity, and shortened life span, was estimated at $83 billion dollars a year in the United States alone for the year 2000. Depression is second only to cancer in terms of economic impact, and approximately the same as the cost of heart disease and AIDS. The number of deaths from suicide in the United States each year (33,000) is approximately twice the number of deaths from AIDS, and shows no sign of declining. And the impact will only get worse: if current trends continue, children today will develop depression at the average age of twenty, instead of the thirty-plus we are used to. Yet only a third of people with long-term depression have ever been tried on antidepressants, and only a small number of them have ever had adequate treatment.

If this is all true, if depression is as dangerous and prevalent as I’m saying, you may well ask: Where’s the big national foundation leading the battle against depression? Where’s the Jerry Lewis Telethon and the Annual Run for Depression? Little black ribbons for everyone to wear? The obvious answer is the stigma associated with the disease. Too much of the public still views depression as a weakness or character flaw, and thinks we should pull ourselves up by our own bootstraps. And all the hype about new antidepressant medications has only made things worse by suggesting that recovery is simply a matter of taking a pill. Too many people with depression take the same attitude; we are ashamed of and embarrassed by having depression. This is the cruelest part of the disease: we blame ourselves for being weak or lacking character instead of accepting that we have an illness, instead of realizing that our self-blame is a symptom of the disease. And feeling that way, we don’t step forward and challenge unthinking people who reinforce those negative stereotypes. So we stay hidden away, feeling miserable and blaming ourselves for our own misery.

This is a dirty little secret of mental health economics: if you’re depressed, you don’t think you’re worth the cost of treatment. You feel guilty enough about being unproductive and unreliable; most likely your family members have been telling you to snap out of it, and you believe you should. You’re not likely to shell out a hundred dollars an hour to see a therapist, and if your insurance won’t pay, you’re not likely to put up a fight. Yet your therapist needs his fee, and insurance carriers often require you to be very determined before they will pay their share. They will play on your own guilt about your condition to make it difficult for you to get anything more than the absolute minimum treatment. They count on discouraging you from pursuing your claims in order to save themselves money; and, in doing so, they reinforce your depression. There are hopeful signs about “parity” for mental health services, but until the laws are changed and new regulations published, managed care plans still will find ways of drastically restricting coverage for outpatient care.

The decade between 1987 and 1997 brought extraordinary changes in how depression was treated in the United States, trends that have very likely continued since. The percentage of people being treated for depression tripled in that time, from less than one percent to 2¹ ³ percent (while the percentage of people receiving healthcare treatment of any kind actually declined slightly). But all that growth was due to the appearance of new drugs on the market. In 1987, 37 percent of people being treated for depression were taking an antidepressant; in 1997, it was 75 percent. Meanwhile, the proportion receiving psychotherapy declined from 70 to 60 percent, and the average number of therapy sessions declined as well. SSRIs (selective serotonin reuptake inhibitors; the new class of antidepressants — Prozac, Zoloft, Paxil, Celexa, Lexapro) were not generally available in 1987, but within ten years they were being prescribed to almost 60 percent of patients. By 1998, more than 130 million prescriptions for antidepressants were written each year in the United States, and Prozac, Paxil, and Zoloft were among the six best-selling drugs of any kind. By 2004, fully one-third of U.S. women’s doctor visits resulted in a prescription for an antidepressant. By 2005, 10 percent of the American population was taking an antidepressant. Here you have the intersection of two factors: the direct-to-consumer advertising of (and all the media hype about) the newer antidepressants, and the advent of managed care, which often requires treatment by a physician (not a psychiatrist), and reimburses less for psychotherapy. Most experts agree that treatment with medication and psychotherapy combined is best, but very little research is being conducted on combined treatment because in the U.S. drug companies fund research, and they’re not interested in supporting that conclusion. So psychotherapy for depression became the exception, and a scrip from your GP became the norm. Depression became chemical, and there was no need to look at the stresses in your life.

Then the news began to trickle out that medications weren’t so effective after all. We learned that in their testing, they had proved only slightly better than sugar pills, that the testing used measures that were designed to exaggerate the success of the meds, and that over the long haul, most people using them relapsed. We learned that the side effects were far more pervasive and serious than we had been led to believe, and subsequently realized that depression can’t be brushed off as a chemical imbalance.

Despite greater awareness and all the pills prescribed, depression remains amazingly underdiagnosed. That same study showing the remarkable expansion in treatment still notes that most people with depression get no treatment at all. Many people don’t realize they have it. When I worked at our community mental health center in rural Connecticut, we would see two or three new people every week who had trouble sleeping and other physical symptoms, felt anxious and overwhelmed, had lost ambition and hope, felt alone and alienated, were tormented by guilt or obsessional thoughts, may even have had thoughts of suicide — but they wouldn’t call it depression. They just concluded that life stinks and there was nothing they could do about it. They would go to their doctors for aches and pains, sleeplessness, lack of energy, and get a useless prescription or medical procedure or be dismissed as hypochondriacs. They might medicate themselves with alcohol and drugs. Their families didn’t know how to help; neither sympathy nor moralizing seemed to have any effect. In this way, the depressed person gets caught up in a vicious circle from which there seems to be no escape. Life like this does stink, especially when you blame yourself and don’t realize you have an illness.

Untreated depression will damage the course of your life. Men with early onset (before age twenty-two) major depression are only half as likely to marry and form intimate relationships as men with late-onset (or no) depression. Women with early onset depression are only half as likely to obtain a college degree as their female counterparts, and their future annual earnings will be substantially lower.

The real tragedy is that in mental health, where there is so much we can’t help, depression is one thing that can usually be treated effectively and efficiently. Many good, unbiased research studies have shown that treatment works. Most people improve quickly; though total recovery is often a slow, challenging process, it’s well within our grasp.

Janet was admitted to a psychiatric hospital in an acute state of depression. She was extremely upset and confused, could not organize her thoughts, could not drive to the store or take care of her children. She was obsessed with thoughts and impulses of suicide, though she did not consciously desire to kill herself. She couldn’t sleep, felt hopeless and helpless, and had lost all interest in ordinary activities. She was convinced she was losing her mind.

This all seemed to start recently when Janet found out her husband had had an affair. Although he seemed ashamed of himself and assured her it would never happen again, her world seemed to collapse. Within a few weeks, her ability to function had deteriorated dramatically. Her husband brought her to the family doctor, and together they arranged for an emergency admission.

After a week in the psychiatric ward, Janet felt much better. Just before she was ready to be discharged, she went home on a weekend pass. Her visit went smoothly until Janet discovered a letter her husband’s girlfriend had written to him while Janet was in the hospital. Again he tried to reassure Janet that the affair was over. But her condition took a dramatic turn for the worse, and she spent several more weeks in the hospital.

Depression is a fascinating condition. There is a great deal of value in thinking of it as a disease. The brain chemistry of depressed people is different from that of other people, and it is possible to find the same biochemical differences in the brains of animals that appear “depressed.” Over the long term, depression seems to result in loss of brain cells and shrinkage of certain parts of the brain (see Chapter 4). On a human level, helping people understand that they have a disease can free them from much of the guilt and self-blame that accompanies depression. They can learn different ways of reacting to stress and learn to take steps so that the danger of future episodes is greatly reduced.

But if it’s a disease, how do we catch it? If Janet’s husband hadn’t had his affair, would she ever have come down with depression? There was nothing about her to suggest susceptibility to depression before she got sick. Janet now thinks she has had a “breakdown,” she now thinks of herself as a mental patient — but isn’t this because her husband is a jerk? Is the depression in Janet, or in her marriage? If it’s in her marriage, how can the pills Janet takes help her feel more competent and capable? If it’s in Janet, is it the part of herself that sees the truth more clearly than she and her husband can admit to?

Most people who have had a true experience with depression have no trouble at all believing that something biochemical in nature has happened to them. The change in mood, in how the self and the world are perceived, seems so profound and overwhelming that it makes intuitive sense to feel that the self has been invaded by something alien. We do not feel like our selves. Something very powerful, something from outside us, has invaded and changed us.

But most people going through their first experience of depression also recognize that this feeling that seems so foreign is also eerily familiar. They remember many times from their childhood and adolescence when they felt the same way — alone, helpless, and friendless. They may remember their parents as kind and loving, but they wonder why they felt so unloved. They may have believed that they had to be perfect, and they may have tried very hard, but failed, and felt again the futility of their efforts. As adults, they may have thought they’d grown out of it, but here it is again. Winston Churchill referred to his depression as the “black dog” — the familiar beast that quietly pads in in the evening and settles down at your feet.

Depression is a disease both of the mind and of the body, the present and the past. In psychiatry now we have pitched battles going on between opposing camps, those who want to treat the brain and those who want to treat the mind — and those interested in the mind are losing the fight. The side that wants to treat the brain has all the support of Big Pharma, traditional medicine, and the gee-whiz media. But their research is almost always flawed. Unfortunately, the patient is caught in the middle. The family doctor, supported by the pharmaceutical industry, is likely to say, “Take this pill” — but when it doesn’t work, the patient just has another in a long line of failures to add to his baggage. The mental health professional is likely to say, “Let’s talk about it” — and the patient is likely to feel patronized, misunderstood, because how can simply talking lift such terrible pain?

It’s not an either-or question. Both ways of thinking are true. Psychotherapy and medication both produce similar changes in brain functioning. There is a biochemical process in depression, but the individual has been made susceptible to depression through life experiences. The current episode may be precipitated by an external event, but the event has set in motion a change in the way the brain functions.

When he was in his thirties, Robert went to bed for fourteen months. He was profoundly depressed, though he didn’t acknowledge it. A highly intellectual man, his mind was preoccupied with questions about the meaning of life. Unable to find a reason for living, he saw no reason to get up. He didn’t consciously feel depressed, he just felt empty. His wife did everything she could to get him out of bed — brought in doctors, family members, appealed to his duty to their child. It became a bitter power struggle between them. Finally, one day long after his wife had given up, Robert decided to get up and go back to work.

I got to know Robert fifteen years later. He had had other episodes in which he took to his bed for weeks, but never for so long. He and his wife had been separated for a few years, when she finally tired of his coldness.

Robert came in for treatment because he feared slipping back into his old ways. He lived alone now, in a house literally crammed with junk. There were days when he just couldn’t get out of bed. When he did, he procrastinated and couldn’t accomplish anything. He was troubled by his wife, who seemed bent on a nasty divorce battle. He still saw absolutely no purpose in living, but he wanted to resolve the divorce. He was dead set against medication of any kind, and since he never went into a major depressive episode while we worked together, I didn’t push it.

Robert had exactly the family background that is so common among depressed men: a critical, distant, hostile father and a shallow, narcissistic mother. He felt he could never satisfy his father or interest his mother. Because children can’t see their parents objectively, they make the way their parents treat them part of themselves; if you are treated like dirt long enough, you begin to feel like dirt. Instead of understanding that Father is too critical, the child experiences himself as inadequate; instead of understanding that Mother is cold, the child experiences himself as unlovable. These feelings persist into adulthood as the basis for a characterological depression, an existence without hope or joy.

I decided to try to go with Robert’s strengths: his intelligence, his intellectualized curiosity about the meaning of life, and his recognition that the world of feelings was foreign territory. I suggested that he do some reading so that he could better understand his own condition. Robert was fascinated with Alice Miller’s book Prisoners of Childhood, understanding that she was describing his parents and childhood with perfect accuracy. He learned that depression is not a feeling, but the inability to feel. He began to learn that when he felt like taking to his bed, it was in response to some interpersonal event. He wanted to learn better ways of responding.

Eventually Robert began a relationship with Betty. With Robert’s permission, Betty came in to see me; her devotion to him was obvious, but I was especially pleased with her “tough love” approach. She helped educate Robert about feelings. When he got mad at her, she wouldn’t let him withdraw. She teased and joked him out of his coldness. For his part, he was so moved by her evident love for him that he wouldn’t let himself act like the aloof, self-absorbed iceberg he used to be. Instead of ruminating about the meaning of life, for the first time he began to enjoy living.

The crisis in therapy came after a few months. Betty decided to move away from our small town, which had no jobs available. She had family in another state that would help her make a new start. Robert could come too. But he got caught up in obsessional thinking. He became terrified that his wife would break in and steal something he didn’t want her to have. But Robert knew intellectually that these worries were really trivial in proportion to the opportunity he had. With his new understanding of depression, he could see that he was displacing his anxiety about change and commitment to seemingly simpler things. Still it was very difficult for him to let go; I had to make him imagine in detail what his life would be like without Betty.

I saw Robert again, three years later. He was in town for another hearing on his divorce, which continued to drag on. He and Betty were living together, and he was working and happy. For at least three years, there was no sign at all of his depression.

What helped Robert so much? Was it the therapy, his relationship with Betty, or something else? How destructive was his marriage? His withdrawal into bed was at least partly a retreat from his wife’s nagging. Would medication have helped him sooner, or helped him even more effectively?

To understand depression, we should ask ourselves, what was it about Robert and Janet that made them respond to life stresses in the way they did? This is what sets them apart from other people. Many wives in Janet’s situation would have questioned their marriage, not themselves. Others might have shrugged off a husband’s affair. What made Janet so vulnerable? How could Robert become so immobilized for so long, and then one day snap out of it? To what extent did his coldness, his inability to feel, which seemed so much a part of him, contribute to his depression?

William Styron, author of Sophie’s Choice and winner of the National Book Award, wrote Darkness Visible to describe his own bout with depression. He referred to his experience as “madness,” feeling that the word “depression” is simply an inadequate expression of the experience — “a true wimp of a word for such a major illness.… Told that someone’s mood disorder has evolved into a storm — a veritable howling tempest in the brain, which is indeed what a clinical depression resembles like nothing else — even the uninformed layman might display sympathy rather than the standard reaction that ‘depression’ evokes, something akin to ‘So what?’ or ‘You’ll pull out of it’ or ‘We all have bad days.’ ”

Styron was right. People feel ashamed of being depressed, they feel they should snap out of it, they feel weak and inadequate. Of course, these feelings are symptoms of the disease. Depression is a grave and life-threatening illness, much more common than we recognize. As far as the depressive being weak or inadequate, let me drop some names of famous depressives: Abraham Lincoln, Winston Churchill, Eleanor Roosevelt, Sigmund Freud. Terry Bradshaw, Drew Carey, Billy Joel, T. Boone Pickens, J. K. Rowling, Brooke Shields, Mike Wallace. Charles Dickens, Joseph Conrad, Graham Greene, Ernest Hemingway, Herman Melville, Mark Twain.

Depression accounts for a large part of the business in most outpatient practices. At our clinic, we could see a big difference between self-report and diagnosis; only 12 percent of people told us when they first called that depression was their primary problem, but 45 percent of our patients ended up with a diagnosis of some form of depressive disorder. People usually called not because they were aware they were depressed, but because the depression had reached the point where their lives were in crisis — marital problems, drug or alcohol problems, trouble at work. But we would see someone who looked sad, tired, and defeated, couldn’t sleep, was irritable, hopeless, and blamed himself for the situation. Depression often grows in us so slowly that neither we nor those close to us notice the change, while an objective observer detects it right away. When I first decided to try medication and consulted a psychiatrist who knew me socially, I asked if he thought I might be depressed. He was amazed that I didn’t know.

Depression most often strikes young adults, but 10 percent of all children suffer an episode before age twelve, and 20 percent of the elderly report depressive symptoms. Both children and the elderly are amazingly undertreated. Estimates are that six million elderly persons suffer from some form of depression, but that three-quarters of those cases are undiagnosed and untreated, despite regular routine medical care. Depression in the elderly tends to get dismissed as inevitable, but in fact it is caused more by poor health and poor sleep than grief, loss, and isolation. Among the elderly who commit suicide, almost three-quarters visit a doctor within a week before their death; but only in 25 percent of those cases does the physician recognize a depression. In long-term care facilities, most of the patients are given some form of antidepressant, but is this because they are depressed, or to make them less sensitive to their living conditions? Do we call it depression if they are correctly seeing that the world treats them as useless and forgotten?

Twenty-five percent of all women and 11.5 percent of all men will have a depressive episode at one time in their lives. But this reported lower incidence among men may really be a mistake arising from the way we diagnose. Men are socially prohibited from expressing or even experiencing the feelings associated with depression. Instead, they act them out through substance abuse, violence, and self-destructive behavior. Across the United States, four men commit suicide for every woman who does, a dramatic reversal of the differences in reported depression. In Amish culture, where macho acting out is frowned upon, the incidence of depression is the same for both sexes. See Chapter 11 for a more thorough discussion of these sex differences.

Suicide, the “worst case” outcome of depression, is officially the tenth most common cause of death in America. There are 33,000 documented suicides annually, but the true incidence is probably double that (because police and medical examiners prefer not to label ambiguous, solitary deaths as suicide). One out of every two hundred people will eventually take their own lives. And although I personally think that suicide can sometimes be a rational choice for people who are in intractable pain or facing great disability, the vagueness of the boundary lines means that we have no reliable data on how many suicides are people who are really depressed, versus how many are “rational.” My experience is that far, far more suicides are truly depressed. Among adolescents, the suicide rate has quadrupled in the past twenty-five years. A few years ago in a small city near where I work, there were eight suicides among young people in one year. These were usually young men just out of school, often intoxicated, usually with no “warning signals” beforehand. An angry, bitter kid who has an unexpected disappointment, gets drunk, and has a gun close at hand is a disaster waiting to happen.

When I still worked in Chicago, I got to know Jane, whose twenty-year-old son had shot himself while she slept in the next room. This was a young man no one would have described as depressed; rather he was a troublemaker. With a history of arrests for minor offenses as a juvenile, he had been sent to a reform school when he was fifteen. Since being discharged, he had lived off and on with Jane and with friends. He worked occasionally, drank a lot, and got into fights.

On the night he took his life, Jimmy had two pieces of bad luck that probably put him over the edge. First he met his ex-girlfriend at a local hangout; she went out of her way to be snotty to him. Then he ran into his father at another bar. A true town drunk, the father barely recognized his son; when he did, it was to ask him for money.

Jimmy came home about midnight. His mother woke, got up and spoke to him, asking him if he needed anything. He was drinking a beer and reading a magazine, and as far as Jane could see, he was his usual self. She went back to bed. Jimmy went to his room and wrote a brief note, more a will than a suicide note. He wanted his brother to have his motorcycle, snake, and hunting rifle. Then he shot himself with the hunting rifle.

Jane kept asking me why. I couldn’t tell her what I thought was the true answer to that question, because I thought it was too cruel, but in my opinion she and her son were as much victims of chance as anything else. If you take any sample of impulsive, alcoholic young men whose lives are going nowhere, get them drunk, expose them to rejection, and leave them alone with a gun, some of them will shoot themselves. Which ones take their lives on any given night is just the law of averages. Are they depressed? They sure are, but they can’t admit it or show it.

Jane is like most survivors of suicide I’ve known. You certainly don’t get over it, but you learn to live with it. She was depressed herself for over a year, had terrible headaches (a psychosomatic symptom mimicking her son’s injury), was unable to work, became overwhelmed with stress, and went from doctor to doctor seeking relief from her pain. Antidepressant medications didn’t help; all I could do was listen while she grieved. Eventually her headaches became less frequent and she began to have a little more energy to put into her life. I think of her every time I hear of an adolescent suicide.

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Excerpted from Undoing Depression by O'Connor, Richard Copyright © 2010 by O'Connor, Richard. Excerpted by permission.
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