Lesson 1: Different Types of Depression
Different Strokes
Atypical depression is a gross misnomer, as this is probably the most common type of depression. The DSM-IV defines atypical depression as a major depressive episode but where a patient's mood can respond to external events (allowing him or her to temporarily feel happy), plus the absence of melancholic or catatonic features, and two or more of the following: appetite increase or weight gain, excessive sleep, leaden paralysis, or sensitivity to rejection. Those suffering from classic or melancholic depression, by contrast, are more likely to manifest the opposite symptoms, eg lack of sleep and appetite and weight loss. People who have bipolar depression and Seasonal Affective Disorder are more likely to manifest atypical features.
Dysthymia is commonly known as mild to moderate depression, which is like saying a mild or moderate hurricane. If we think of major depression as a spectacular brain crash, milder depression can be compared to a form of mind-wearing water torture. Day in and day out it grinds us down, robbing us of our will to succeed in life, to interact with others, and to enjoy the things that others take for granted. The symptoms are similar to major depression, with feelings of despair and hopelessness, and low self-esteem, often accompanied by chronic fatigue. This can go on for years, day in, day out. Still, we are able to function, a sort of death-in-life existence that gets us out into the world and to work and the duties of staying alive then back to our homes and the blessed relief of flopping into our unmade beds.
Untreated, dysthymia is major depression waiting to happen. The same treatments that apply for major depression also work for dysthymia, and some, such as St John’s wort, are especially useful.
Seasonal Affective Disorder is commonly known as winter depression. In the fall of 1975 I moved to Vancouver to be with my fiancee. There, in Kitsalano, where the hippies hung out, one could wake up to a breathtaking view of the ships in the harbor and the snow-capped mountains behind North Vancouver. But nine days out of ten, the clouds dropped to treetop level, discharging a light mist that carried the intoxicating scents of the nearby forests into the city but also creating a filmy shroud that settled over every landmark in the vicinity.
"They took away the mountains," I would half-joke to my fiancee, not used to a force that could turn mighty peaks invisible. Then December approached, and with it a Stygian darkness that descended at four in the afternoon and snuffed out the murky gray that passed for light in this part of the world.
The world didn’t know about seasonal affective disorder (SAD) back then, but not long after Dr Nathan Rosenthal of South Africa moved to New York, where he experienced the same kind of mood change I went through. He also noticed his depression lifted when spring arrived. Not long after, at the NIMH, he met Herb Kern, who had been through a similar experience. Rosenthal began exposing Kern to light, and almost immediately noticed a marked improvement in his mood. In 1984, Rosenthal authored a ground-breaking article, and not long after the psychiatric profession gave the new condition its official seal of approval, complete with an entry in the DSM-IV.
Light therapy is the treatment of choice. A light box is the standard device, one that produces at least 2,500 lux at a table or eye level, but light visors are also effective. Outdoor walks and indoor activities by the window should be considered a form of light therapy. Even an overcast day produces light equivalent to a light box.
Depression with psychotic, manic, or agitated features In rare cases, people with depression can lose touch with reality. Andrea Yates, the Texas mother who drowned her five children, is an extreme example of psychotic depression. People with bipolar disorder or manic depression tend to present with atypical features, but there is a subtype of bipolar called mixed, where a person can be depressed and manic at the same time. In a mixed state, an individual can be depressed while extremely agitated or in a manic or very high state while feeling very distressed. Experiencing agitation is also one of the nine symptoms listed in the DSM-IV for unipolar depression.
Child and Teen Depression is often bound up in other behaviors and disorders, ranging from anti-social behavior to attention deficit disorder to over-eating to substance abuse. Confusing the issue is the fact that early-onset depression can manifest itself in ways not normally associated with adult depression, such as high anxiety and agitation, and on top of this many adults do not believe kids are capable of having depression. According to a survey of youth near-suicides, parents perceived depression in their children only 13 percent of the time (versus 57 percent subsequently diagnosed).
Making matters worse is the fact that kids, ever sensitive to stigma, are not inclined to speak up. According to one expert, speaking at a White House Conference on Mental Illness: "Teenagers are never volunteering to be customers for mental health services."
Women suffer depression in twice the numbers as men, making it the greatest health problem for their gender. With the onset of puberty, women begin suffering far more than boys, possibly because they are more socially-oriented and more dependent on positive social relationships. Also, girls may dwell more on negative events than do boys. Poor young women, according to a 1999 report of the Surgeon General, "have disproportionately higher rates of past exposure to trauma, including rape, sexual abuse, crime victimization, and physical abuse; poorer support systems; and greater barriers to treatment, including financial hardship and lack of insurance."
Neurobiology and reproductive cycles also factor in. The Surgeon General concludes: "Something about the environment thus appears to interact with a woman's biology to cause a disproportionate incidence of depressive episodes among women."
Postpartum Depression represents a new mother’s worst surprise. At one end of the spectrum are the "baby blues," affecting some 50 to 70 percent of new moms, with onset occurring within three days to a month after delivery, and a duration of less than ten days. At the other extreme is postpartum psychosis, affecting one in 500 births, accompanied by hallucinations, delusional thoughts, and agitated behavior (turned into tabloid fodder by Texas mom Andrea Yates drowning her five children in 2001).
Then there is postpartum depression, affecting some 10 to 15 percent of deliveries. The term postpartum merely refers to the triggering event. This is major depression, pure and simple, but with this cruel twist: A combination of ignorance and misplaced expectations - both on the part of the new mother and those who should know better - conspire to cause far more suffering than necessary.
Men have their own particular vulnerabilities, especially as they near age 50. According to Steven Roose MD of Columbia University: "It is striking that vascular disease, erectile dysfunction, decreased testosterone, and suicide are all strongly associated with depression."
Terrence Real, author of “I Don’t Want to Talk About It: Overcoming the Secret Legacy of Male Depression”, describes depression as an "auto-aggressive disease," of the self attacking the self. Recovery is about connecting with the hurt and trauma that lies beneath.
Elderly depression is a public health time bomb ticking away as the baby boomers start trading in their walkmans for walkers. About 70 to 80 percent of the depressed elderly go unspotted in primary care practice, their symptoms generally mistaken for other ailments. The depression itself tends to impede recovery from other illnesses and injuries, intensifying the pain and suffering of other medical problems, and creating a condition of hell on top of hell that all too often demands ultimate release. It's one of those bitter facts of death that tend to get swept under the carpet: suicide in the elderly far exceeds the population as a whole. Amongst elderly white males, the suicide rate is six times the national average. Amazingly, 75 percent of these had seen a doctor within the last month.
Poverty and depression is the strongest section of Andrew Solomon’s “Noonday Demon”. According to figures cited in the book, 42 percent of heads of households receiving Aid to Families with Dependent Children meet the criteria for clinical depression - more than twice the national average - and 53 percent of pregnant welfare mothers are in the same condition.
"Virtually all of America’s indigent," he writes, "are, for obvious reasons displeased with their situation; but many of them are, additionally, paralyzed by it, physiologically unable to conceive of or undertake measures to improve their lot. In this era of welfare reform, we are asking that the poor pull themselves up by their bootstraps, but the indigent who suffer from depression have no bootstraps and cannot pull themselves up."
Conclusion
Now that you know what you're up against, you are in a position to fight it, and win that fight. Depression may be a beast of many heads, but each one can be taken out by essentially the same array of weapons. Our next three lessons will look at what you can do to manage and cope with your illness. In the meantime, you are encouraged to participate with other students by answering the questions in the next section.
