COVER

THE AGONY OF DEPRESSION

Jane O’Hara March 19 1984
COVER

THE AGONY OF DEPRESSION

Jane O’Hara March 19 1984

THE AGONY OF DEPRESSION

COVER

Jane O’Hara

In its milder form, depression is known as “the blues” and it is a normal reaction to the chronic disappointments and low-grade frustrations caused by modern life. In most cases depression lifts and people get on with their lives. But for those deeply snared in its web, depression can be a debilitating disorder which infects body and mind with a lingering, soul-destroying sadness. Laurie Malinsky, a Calgary mother of two, recalled a 1976 depression in which she spent six weeks curled up under the covers in bed: “I was paralysed by fear. If I had the choice between a horrible disease and just two hours a day of the hell I was in, I would have chosen the disease.” Recently, researchers have launched a renewed, almost feverish campaign to find a cure for people like Malinsky. But it has become a controversial quest. Throughout Canada and the United States the traditional assumption that depression is psychological in origin and can be cured on the couch is losing currency. Increasingly, experts on depression are using brainchemistry research in laboratories to try to decode the biochemical enigmas of the condition.

Although the exact causes and cures for depression have eluded scientists, its victims and effects are well-known. Researchers estimate that one in five Canadians suffers a major depression at some point in his or her life and that unemployment heightens the risks. Women will be afflicted six times more often than men. Said Dr. Vasavan Nair, director of Montreal’s Douglas Hospital’s Research Centre: “More people suffer depression than any other single illness.” What they suffer from is a mood disturbance that causes feelings of worthlessness and despondency. Said Dr. Peter Brown, a depression researcher at McMaster University Medical Centre in Hamilton, Ont.: “Depressed people tend to be very self-critical. It is as though they have their own booing section.” They are not alone. Said Toronto teacher Eleanor Wright Pelrine, who has battled depression all her life: “It rendered me virtually help-

less to do anything or to deal with anything.” The psychological impairment is often accompanied by such physical maladies as sleeplessness, weight loss, headaches, vague pains and fatigue. Sufferers no longer care about normal daily activities and complain that something has gone wrong in their head. Indeed, when Margaret Trudeau experienced a severe bout of depression in October, 1974, she described it as “a bloody revolution in my mind.” Said Winnipeg mental patient rights activist Kendra June, who had to spend nine years in hospital because of schizophrenia and depression: “It was just a total helplessness, a powerlessness over my situation with no control over my life at all.” Agreed Montreal mother of four Louise Cantin, who suffered a severe depression in 1975: “I was feeling like trash. Sometimes I would sit in the living room banging my head against the wall, wondering why this was happening to me.”

Worldwide toll: Increasingly, doctors and health officials have come to realize the worldwide toll that depression takes on individuals, families and society. According to Brown, depressed people have six times more marital failures and three times more serious problems in school than the general population. They are also more likely to be alcoholics. As well, studies have shown that people suffering from untreated depression have two to three times more heart attacks and are significantly more likely to die of cancer or suicide than the general population.

The reports take on startling significance when they are linked with studies that show that close to 75 per cent of all depression goes undiagnosed. According to Vancouver’s Dr. Ronald Remick, head of the Affective Disorder Clinic at Shaughnessy Hospital, the reason so much depression remains untreated is that many people, especially men, think of it as a mental weakness that they do not want to acknowledge. Said Remick: “Many people will just explain it away by saying they are having a bad day or a bad month related to some problem in their lives. Often, however, it is not psychological; it is physical. If people accepted that, there would

be less stigma about going to a shrink, and people could get treatment.”

The wide swath that depression cuts through society has earned it a reputation among physicians as “the common cold of mental disorders.” According to a 1983 study by the Geneva-based World Health Organization (WHO), titled Depressive Disorders in Different Cultures, an estimated 100 million people develop a recognizable depression each year. In the United States the Bethesda, Md.-based National Institute of Mental Health (NIMH) estimates that depression costs $20 billion every year in treatment and lost productivity. And medical experts worldwide assert that depression is on the rise.

At Montreal’s Douglas Hospital, doctors diagnosed 25 per cent of the hospital’s 3,600 psychiatric outpatients last

year as depressed. In Vancouver, psychiatrist Dr. Ingrid Pacey said that depression is part of the problem for about 95 per cent of her largely female case load. Indeed, although modern society, with its stresses and shifting social values, did not invent depression, it appears to be on the way to perfecting it. Said Robert Wilson, a Vancouver industrial psychologist: “Although depression may be as prevalent as the common cold, it sure is not so easy to get rid of.”

Pain: For families, the pain of living with a depressed parent, spouse or sibling is often unbearable and creates an enormous drain on emotional resources. The numbers of people who have sought help and information about depression have taken health officials by surprise. In Vancouver the local branch of the

Canadian Mental Health Association (CMHA) recently held a three-night seminar for friends and relatives of depressed people. Within hours of the announcement of the meeting 200 people had signed up, and CMHA officials had to turn away almost 180 more. Said Christine Noon, a 22-year-old student who attended because she had watched a depressed friend experience severe anguish: “I think there is a collective depression around that is affecting more people now than ever before. It makes me angry that no one knows how to deal with it.”

Discovering the root causes of depression has been a forbidding task and one that dates back to Hippocrates in the 4th century BC. At that time, the Father of Medicine described depression as “darkening the spirit and making it

melancholy” and concluded that it was caused by bodily “humors” and black bile. In the 1880s Sigmund Freud swallowed cocaine to treat his own depression, then wrote Mourning and Melancholia in an attempt to explain its psychological causes. In the 1930s the discovery that electroconvulsive therapy (ECT) could snap severely depressed people out of their depression was a boon to scientists who believed that it had biochemical roots. In the 1960s the widespread use of antidepressant drugs further fuelled biochemical research into depression.

Stress: Researchers today universally acknowledge that depression is often a multifaceted problem. It is almost always linked to stress that acts in conjunction with an existing psychological or biological vulnerability. Said Remick: “Psychological stress can trigger it, or it can come out of the blue. We do not know—except that the end stage is a medical illness.” Indeed, the loss of a job or the breakup of a marriage can bring on depression. But, because recent biochemical evidence indicates that emotional changes affect the chemical activity of the brain, researchers now believe that in many cases brain chemistry may actually induce certain types of depression. It is a theory that is generating great excitement among biochemical researchers and concern among some other mental health profes5 sionals. In depression the probg lem is a shortage of two biochemit cals, norepinephrine and seratonin. They are chemical neurotrans2 mitters which act as messengers ° between nerve cells, conveying impulses throughout the brain. It is not known exactly why a shortage appears to cause a mood disorder, but increasingly the concept guides the treatment of depressed patients. That, along with growing skepticism about the economic costs and effectiveness of psychotherapeutic counselling, has made antidepressant drugs the cornerstone of most clinical practice. Said Dr. Matthew Rudorfer, NIMH staff psychiatrist: “There is no question that biological psychiatry is in the ascendance. The reason is that psychological theories and therapies have neither explained nor helped all causes of depression, whereas some of the biological treatments such as ECT and antidepressant drugs clearly work.”

The search for answers to the biology of mood has recently created an array of psychiatric subspecialties involving geneticists, neuroscientists, virologists

and biochemists who are trying to discover how emotional states affect chemicals in the brain. In keeping with the trend, psychiatric training has begun to put increasing emphasis on biochemistry and neurology, and in most major North American centres there are now mood clinics involved in research. Although research is still in its infancy, the debate over whether depression is a medical disorder that should be treated with drugs or a psychological problem that must be treated with counselling has become highly controversial. Historically, mild to moderate depressions were treated by therapists who exam-

ined the psychological and social factors that appeared to cause the depression. That entailed hours of psychotherapy designed to root out personal problems and find ways for people to cope with their lives. But if today’s claims from the laboratory stand up, they may radically alter the way people are treated for depression in the future. Said Vancouver’s Remick: “In 10 years we will have a simple test, something along the line of a throat culture, to diagnose whether people are depressed. Then we will simply start them on a suitable course of drugs. Anyone who does not believe that is in the Dark Ages.”

The notion that depression is caused by faulty wiring in the brain has led to unprecedented research on the brain’s chemical activity. That is why researchers at Douglas Hospital are currently conducting experiments in which 60 patients undergo sleep deprivation for 36 hours at a time to determine the relationship between chemical activity, the body’s internal rhythms and mood disorders. According to previous U.S. research, two rhythm cycles in the brain control human activity—one oversees sleep and wakefulness, the other regulates body temperatures. In turn, those are controlled by what scientists call neuro-pacemakers—groups of brain cells that act like the quartz crystal in a watch to keep the body’s cycles in order. The pacemakers transmit their regulating messages through the chemicals norepinephrine and sera-

tonin, which are deficient in depressed patients. Sleep deprivation, however, increases the functional level of those two chemicals in the brain. Said Douglas Hospital’s Nair: “The degree of the chemical activity determines whether you are sleepy and what kind of mood you are in. Moods change as the level of these chemicals in the brain increases.” Added McMaster’s Brown: “When you reset the brain’s chemical clock, depression goes away.”

Diseases: Researchers are carrying out other studies to determine how depression relates to diseases such as cancer. In Winnipeg, Dr. Frixos Paraskevas and Dr. James Brown, affiliated with the University of Manitoba, are exploring whether a cancer cell can signal the body’s immune system to interfere with brain chemicals and trigger a depression. Experts know that in many cancer patients depression often appears six months before doctors detect the cancer.

For decades studies of the chemical reactions in the brain have been hampered by the inability of researchers to physically test their theories. In the past, scientists were forced to do autopsies on brains to piece together the mechanics of the living organism. Now, the development of the PET (Positron Emission Tomography) scan, which can take computerized pictures of the brain, makes it possible to trace and photograph various biochemical activities in the brain as they occur. Even though researchers have discovered differences

in biochemical activity between depressed and normal populations, no one knows what those differences mean. Although there have been certain advances, research is still at a primitive stage. Ten years ago doctors thought there were only eight chemicals in the brain. Since 1980, however, scientists have identified another 48.

As well, depression researchers are beginning to understand that it is no longer sufficient to look for simple surpluses or shortages of norepinephrine and seratonin. Instead, they now realize that a full understanding of how the two chemicals work with one another is more important. Said Rudorfer: “We have always thought that seratonin or norepinephrine work on separate tracks, but now we think that there is a connection in the brain between the two

tracks which we know nothing about. There is probably a lot more cross-talk between the two chemicals than we had ever realized. Clearly, a lot of our initial theories on this were quite simplistic.”

Drugs: And while the public waits for definitive answers from the laboratories, more and more doctors have begun to treat depression by adjusting the body’s chemistry with drugs. For one thing, it is often less expensive. And it is faster. However, in most cases the high degree of success claimed for drug therapy is achieved only with severely depressed patients. The drugs bring patients back to a level at which they can respond to psychotherapy. But in cases in which doctors prescribe such drugs

as imipramine and amitryptyline for mildly or moderately depressed people, the results are far less clear.

According to Peter McLean, a psychologist at Vancouver’s University of British Columbia, drugs do not work for almost 50 per cent of all depressed patients (see box). Some cannot tolerate the side effects, which range from blurred vision to skin rashes. In other cases, the drugs do not even ease the depression. Said UBC psychologist Keith Dobson: “We are not sure what the drugs actually do. They do not teach people anything about themselves. When they come off them, their attitudes are just as dysfunctional as ever.” Agreed Winnipeg’s Kendra June: “I never learned to cope with depression without drugs.”

Even pro-drug researchers admit

that today’s antidepressant drugs are far from perfect. Although they may alter the chemical process that returns a patient’s mood nearer to a more normal level, they also affect parts of the brain that have nothing to do with the disease. Said Rudorf er: “We have a long distance still to go.”

More importantly, perhaps, _

there is increasing evidence that certain widely prescribed drugs, which are used to combat stress and anxiety and to prevent hypertension, may also cause depression. According to Dr. John McNeill, a pharmacologist at UBC, flurazepam, the most commonly prescribed sleeping pill, can initiate depression if the dose is too high. It is particularly common in the elderly, who have more trouble breaking down the drug. It is also ironic that certain drugs, such as diazepam, used to allay anxiety and sleeplessness in depressed patients, can also deepen depression. Said McNeill: “Antianxiety agents, by their nature, depress parts of the brain. In too high a dose they will depress all parts of the brain.”

Psychoanalysis: Many re-

searchers believe that the trend toward biochemical treatment is not healthy. Said McMaster’s Brown: “Fifty years ago psychiatrists believed that the only way to deal with depression was

through psychoanalysis. Now they have swung the other way. They want to don the white jackets and pretend they are internists.” UBC’s McLean believes that 70 per cent of all depressions are caused by problems that arise from coping with life’s challenges. He said: “More and more people are trying to treat depression as a physical illness—but devoid of evidence. There is a real danger in mak-

ing it sound like an illness beyond one’s control—that is, locked in by genetic codes that can only be helped by professional treatment. It deprives many people of developing personal coping mechanisms.” Added Lester Krames, a Hamilton psychologist: “If the treatment is not holistic, including drugs if necessary, and therapy, then it is doomed to failure. We know that we can

_ elevate moods with drugs, but

people inevitably come back for more treatment if you don’t restructure their thinking.”

Self-esteem: It is the attempt to decipher the thinking pattern of people with a history of depression that occupies the other major wing of depression research. More traditional psychologists explore the kinds of people who become depressed and the outside stresses that trigger the onset of the illness. In many cases, depressed people have a low level of self-esteem and aggravate their feelings of inadequacy by setting unrealistically high standards for themselves.

McMaster’s Brown has identified two groups of depressed people. Type A is a heart attackprone perfectionist and hard y worker who tends to blame him| self and feel guilty for all his fail§ ures. Type B looks outside himself

0 to place the blame. Said Brown: « “They are the ones most likely to

1 go down to the fridge and stuff i themselves with food.”

Researchers also believe that a sense of powerlessness, of being unable to change one’s life, is also a depression trigger. To illustrate the concept, in 1967 University of Pennsylvania-based psychologist Martin Seligman introduced the phenomenon of “learned helplessness.” Seligman clinically demonstrated what happens when human beings lose hope in themselves, the world around them or the future. In one experiment he wrapped Labrador retrievers in a restraining hammock from which they could not escape and shocked them repeatedly. He then put the dogs in a cage divided along the middle by a low barrier. He first sent an electrical shock through the floor on one-half of the cage. The dogs could have jumped to the other side to escape the shock but they believed that they could not escape the current. As a result, the dogs rolled up in a corner and began to whimper.

According to Seligman, the same response happens in depressed humans when they feel powerless to control the environment around them.

Unemployed: One example of the syndrome appears in depression among the unemployed, where the loss of a job, combined with attendant domestic and psychological changes, can create damaging stress. In a November, 1983, study called Unemployment:

Its Impact on Body and Soul, Toronto-based psychologist Sharon Kirsh explained how the unemployed lose their sense of self-worth and become increasingly powerless. They also tend to blame themselves for being out of work or laid off and begin to believe the conventional wisdom that the unemployed are lazy, unproductive and a burden on the system. Said Kirsh: “Who is more powerless than someone who has no income? But by labelling their depression we are obscuring the power politics that creates that set of conditions.” Janet Tarasoff, a 44-year-old unemployed teacher in Vancouver, knows the feeling of depression well. She became depressed after looking for a teaching job in a province that has been hard hit by education cutbacks. Said Tarasoff: “When I get depressed I feel completely unmotivated. I feel lethargic

and angry. I can shake it as long as I am out talking to people, but if I am alone I just have this draggy feeling.”

As well, researchers explain the disproportionate amount of depression in women by citing their position of relative powerlessness in society that is caused by factors ranging from lower wages to their dependence on men. In a 1978 British study called Social Origins of Depression: A Study of Psychiatric Disorders in Women, researchers George Brown and Tirril Harris theo-

A CHECKLIST FOR DEPRESSION

The questionnaire is called The Beck Depression Inventory* and was developed by Aaron Beck, director of the Center for Cognitive Therapy at the University of Pennsylvania, in Philadelphia. Respondents select a statement from each group, valued zero to three, and total their score.

1. (0) I am not particularly disr , couraged about the future.

L J (1) I feel discouraged about the

future.

(2) I feel that I have nothing to look forward to.

(3) I feel that the future is hopeless, and that things cannot improve.

2. (0) I do not feel like a failure.

r , (1) I feel I have failed more L J than the average person.

(2) As I look back on my life, all I can see is a lot of failures.

(3) I feel I am a complete failure as a person.

3. (0) I make decisions about as r , well as I ever could.

L J (1) I put off making decisions more than I used to.

(2) I have greater difficulty in making decisions than before.

(3) I cannot make decisions at all anymore.

4. (0) I get as much satisfaction

r out of things as I used to.

L J (1) I do not enjoy things the way I used to.

(2) I do not get real satisfaction out of anything anymore.

(3) I am dissatisfied or bored with everything.

5. (0) I do not feel sad.

P (1)1 feel sad.

L J (2) I am sad all the time and I cannot snap out of it.

(3) I am so sad or unhappy that I cannot stand it.

6. (0) I can sleep as well as usual. r , (1) I do not sleep as well as I L J used to.

(2) I wake up one to two hours earlier than usual and find it hard to get back to sleep.

(3) I wake up several hours earlier than I used to and cannot get back to sleep.

A total of 10 or more indicates possible symptoms of depression. If respondents score in that range, Brian Shaw, of Toronto’s Clarke Institute of Psychiatry, recommends a consultation with a family physician or psychologist.

* Reprinted, with permission from Aaron Beck, °1967

rized that working-class women were four times more likely to become depressed than women from middle-class homes. The reason: because of their bad financial state, they have fewer ways of coping with stress and they feel helpless to change their situation.

Vancouver’s Gloria Graham, 39, suffered a major depression in 1969. She was married to an alcoholic, and their relationship was stormy. She had five children, a full-time job, and that year her house burned down. When her depression began, she remembers sending her children to school, then sitting down for a minute—or so she thought. Before she knew it, the children were home for lunch, and she had missed the whole morning. One day she quit her job and within a week she had turned up on her mother’s doorstep, 480 km away, without realizing that she had driven herself there. She checked herself into a hospital and doctors gave her electroshock therapy and drugs. Recalled Graham: “It did not stop the depression. I knew the drugs were bad, but there was no one to talk to.” Today her depressions recur, but they do not last as long. And she has friends who keep a close watch on her. “I used to just lock my door and go to bed for a week,” said Graham, who now works at Vancouver’s Mental Patients Association. “But I do not do it anymore. I have a friend who gives me two days and then will climb through the window and drag me out.” Social roles: Mental health professionals also suggest that women are more rigidly locked into social roles, which can lead to depression. And there are new problems for today’s upwardly mobile women, who try to free themselves of old expectations. Said Vancouver’s Dr. Ingrid Pacey: “I see women whose depressions are due to leaving men, or trying to live with men or without them, who are having problems in the work force. A lot of it has to do with their conflict over social roles.”

For Toronto’s Eleanor Wright Pelrine, 52, the worst depression struck at the age of 20. She was then heavily involved in the labor movement and wanted to become a union organizer, at that time an almost entirely male bastion. Recalled Pelrine: “I was the wrong sex at the wrong time in the wrong place.” Although she was virtually suicidal, many health professionals did not take her depression seriously. Her family doctor said, “Oh, you young girls think too much about yourselves.” Her psychiatrist suggested that her problem stemmed from refusing to be “a traditional woman” and he advised her to try marriage. Although her depressions are far fewer today, she still believes that society trivializes women’s health problems. Said Pelrine: “Women are still being told that if they accept society’s point of view and conform, they will get better. That is entirely wrong. Through therapy I began

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to learn that I had tremendous anger and resentment at being forced into a mould. When I confronted that, the depression lifted.”

In a disturbing new area of research, the psychiatric community has recently accepted the existence of depression in children. In 1967 Dr. Donald McKnew, coauthor with Dr. Leon Cytryn of the 1983 book Why Isn’t Johnny Crying?, noticed symptoms of depression in children as young as 1 whom he was treating at Columbia Presbyterian Hospital in New York City. When he asked lab technicians to check the children’s blood for the same biochemical abnormalities that show up in the blood of depressed adults, they refused to conduct the tests because they did not accept his ideas on childhood depression.

All that has changed, however. It is now estimated that two out of every 100 American children show major depressive symptoms. In October, 1983, at the annual meeting of the American Academy of Child Psychiatrists in San Francisco, almost one-third of the papers were devoted to childhood depression.

School problems: Two of the principal causes of depression in children are the death of a loved one and moving away from friends and school.

Depressed children usually undergo changes in behavior. A child who always enjoyed attending Cubs might suddenly show no interest. Other symptoms can include school problems, disturbed sleep or physical complaints about constant headaches or stomachaches when no real physical reasons are evident. Said McKnew: “Parents are marvellous at picking up external problems a kid is having. But they do not recognize the internal ones.”

But even as developments in depression theory take place at an accelerated pace, they provide little solace for those already afflicted by the terrifying, deadening disease. Two leading therapies in depression research are cognitive therapy, which tries to induce people to think more positively about themselves, and behavior therapy, which works on improving depressive behavior. Behavior therapy is more action-

oriented. Since most depressed people withdraw from pleasant activities and spend most of their time ruminating on their déficiences, behavior therapy encourages patients to set goals and get involved in outside activities. Said McLean: “The idea is to get people success-oriented. The goals have to be realistic, but people are drawn to, and attracted by, successful performance. That is powerful medicine.”

Therapists often use behavior and cognitive therapy in combination. According to Dr. Aaron Beck, a psychia-

trist at the University of Pennsylvania who developed cognitive theory in 1967, depressed people hold certain negative beliefs about themselves: “I’m stupid, worthless”; “Everything’s against me”; and “What’s the use of trying?” According to Beck, the lethargy merely feeds on itself and creates greater and greater distortions. Once caught in this web of hopelessness, the future begins to look bleak. The depressed person becomes locked in a vicious circle of selfrecrimination. Brian Shaw, a psychologist at Toronto’s Clarke Institute of Psychiatry, heads the Canadian portion of a $5-million study sponsored by Bethesda’s NIMH to compare the relative benefits of drug therapy vs. two types of psychotherapy. Said Shaw: “For the moderately depressed, cognitive therapy is as effective as antidepressants.

People do learn how to cope. We forget that nature heals. We would be abandoning people if we only gave them drugs.”

Hopeless: Like thousands of other Canadians who suffer from depression, Laurie Malinsky, the mother of two from Calgary, began attending a selfhelp group to learn how to deal with her lifelong history of anxiety and depression. These groups are a burgeoning movement, largely opposed to the mental health establishment, in the depression field today. At Calgary’s Recovery Inc., Malinsky is a member of one of four groups that meet once a week. Group members avoid the term depression, referring to their condition as “lowered feelings.” Seven years ago, when Malinsky was suffering from a severe depression which she described as “absolutely terrifying and hopeless,” her mother took her by the hand to her first meeting. There, she met six other people who openly discussed their own problems. That gave her courage—and the feeling that she was not alone in a dark world of her own. After six to eight weeks of meetings she began to recover, and now she can cope.

Montreal’s Louise Cantin almost committed suicide as a result of her depression. Now she I is director of the Mong treal-based Déprimés 5 Anonymes (literally, de5 pressed anonymous), a 30,000-member network of 30 self-help groups for the depressed in Quebec. Said Cantin: ‘Talking to the others helped more than the doctors or psychiatrists did.” A large step in recovery from the deep well of depression is the restoration of self-worth. Said Winnipeg’s Kendra June: “I used to see depression as something wrong with me. Now I know that you don’t have to be crazy to be depressed.” Agreed Malinsky: “You learn that it’s the trivial things, like spilling a cup of coffee, that can bring it on, and you learn to deal with that. I still have bad days, but they are no worse than anyone else’s.” For the depressed, that is a major victory.

June Rogers

Michael Clugston

Diane Luckow

Andrew Nikiforuk

Susan Semenac

Ann Finlayson

Dave Silburt