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DEPRESSION, the Black Dog (part 2)


In my previous blog, I introduced the notion of clinical depression and (hopefully) differentiated this from “normal” sadness due to grief or loss. We then discussed the four-part nature of clinical depression (well, okay, there wasn’t actually much discussion. I did all the talking). Now, did you know that there are several kinds of clinical depression? As with other disorders, you can view depression as being on a spectrum, from mild to severe. The different types of depression can also be distinguished by other factors, such as the underlying cause, or the length of each depressive episode. For this blog, I’d like to confine my observations to the two most “popular” forms of depression; Major Depressive Disorder and Persistent Depressive Disorder.


Major Depressive Disorder (aka major depression) tends to receive the most attention in the popular media, at least partly because it has become less stigmatized and has claimed so many lives. It often comes from out of the blue (no pun intended), with no obvious reason or precipitant. It hits like a truck, overwhelming the person with feelings of sadness, hopelessness, and despair. Necessary for this diagnosis are what are known as “vegetative” symptoms, such as anergia (loss of energy and motivation) and anhedonia (loss of interest in things that used to be fun or pleasurable). Sleep is usually disrupted, such that the person sleeps too little (insomnia) or too much (hypersomnia). Also, there is typically weight gain (as a result of “eating for comfort”) or weight loss (from decreased appetite). In major depression, these symptoms become so severe that they ultimately interfere with one’s ability to take care of the normal day-to-day demands of life, such as going to work and keeping up with family responsibilities.


During a major depressive episode, a person will often feel useless and non-productive. This begins a domino effect of guilt, feelings of worthlessness, declining self-esteem… often culminating in the question, “If the rest of my life is going to be like this, why should I go on living?” Mental health professionals refer to this as a passive suicidal thought. If left unchecked, it may escalate to active suicidal intent, wherein the individual forms an actual plan as to how to take his or her own life. Whether suicidal thoughts are passive or active, they must never be ignored, underestimated, or written off as someone just trying to get attention. Emergency treatment should be sought for anyone who entertains thoughts of suicide, or shows any signs of self-harmful behavior.


A diagnosis of major depression is applicable when someone’s mood and demeanor is distinctly different from the way he or she was before the depressive episode. In contrast, Persistent Depressive Disorder (which is also known by the more intimidating name, dysthymia) is more chronic, less extreme, and often more difficult to recognize. This type of depression is less episodic than major depression. In fact, to have this diagnosis, the individual must have experienced depressed mood (more days than not) for at least two years!


Whereas dysthymia has been shown to be more prevalent in women than in men, my experience tells me that men with this disorder are much more likely to go undetected. Why? At the risk of over-generalizing, men tend to be less sensitive to their…um…what are those uncomfortable things called again? Oh, yeah. “Feelings.” As a species, they seem to be more apt to put their heads down, charge forward, and “soldier on,” even when they are sad and joyless.


Many of my older male patients with dysthymia apparently decided early on that it was just their lot in life to be unhappy. Interestingly, most of them did not show up in my office on their own accord; they were “urged” to seek help by their wives or other close family members, who had gotten tired of being married to Eeyore (don’t get that reference?Google it). 


Interestingly, because dysthymia in an adult is more chronic than acute, it used to be thought of as a “personality problem” and actually went by the (now archaic) name, Depressive Personality. However, in children and teenagers, dysthymia usually appears in the form of irritability rather than outright depression. Has your child ever been irritable? Yeah, I thought so. If he or she has been that way (more days than not) for at least a year, you might think about dysthymia. You might also think about getting help for yourself…because, you know, you’ve been living with a grouchy child for a long time.


Regardless of whether someone is suffering from major depression or dysthymia, the good news is that both conditions are very treatable. As I tell all my patients, treatment of depression usually entails two things: medication and psychotherapy. Although each of these works well, neither alone works as well they do together…rather like the two wings of an airplane. Whereas medicine addresses the biological component of depression, therapy helps address some of the psychological and social issues that we talked about last time.


Antidepressant medications relieve the vegetative symptoms of depression. The most popular antidepressants, called SSRIs (Selective Serotonin Reuptake Inhibitors), have relatively few side-effects and also have anti-anxiety properties. As such, they help to break the cycle of anxious, unwanted, ruminative thoughts that seem so hard to ignore (“Why am I so unhappy?” “Will I always be this way?” “What should I be doing about this?”). Once those symptoms have been relieved and the “dark cloud” has lifted somewhat (or, using our metaphor from the last blog, the “black dog” has been put back on the chain), the patient can apply his or her mind to therapy. 


There are many types of therapy, and each type focuses on a different aspect of depression. For example, Cognitive Behavior Therapy (CBT) is a very popular and particularly effective form of therapy that is based on the theory is that your thoughts lead to your depressed feelings, not the other way around. Clinicians who use CBT train patients to recognize and change irrational or unrealistic thoughts that lead to depressed mood. Interpersonal Therapy (IT) focuses on helping a patient navigate and untangle the complicated family and social relationships (got any of those?) that might be contributing to depression. Mindfulness Therapy is a meditation-like technique wherein you learn to calm your mind by being “in the moment,” not thinking about the past (which you can do nothing about) or the future (which isn’t here yet).


Once again, the research robustly suggests that medication and therapy work best as a team. Whenever I propose this two-pronged plan of treatment, the first question the patient usually asks is, “How long?” Let’s face it: almost no one likes to take medication. So, please keep in mind that medication is never intended to be a life-long treatment! However, I usually ask my patients to commit to an antidepressant medication for at least 9 months to a year. That prevents them from giving up too early if they don’t feel better immediately (“See? I knew this wasn’t going

to work!”) or if they do feel better immediately (“Yay! I feel better! Now I

don’t have to take medication anymore!”).


It’s important to understand that antidepressant medications don’t (usually) work overnight. It takes time, sometimes weeks, for them to take effect. Even then, the patient doesn’t just magically wake up “happy” one day. Instead, the changes are subtle: the depressed person slowly discovers that minor things aren’t quite as irritating or bothersome as they used to be. As I tell my patients, medicine will help “increase your ability to tolerate frustration” (sounds wise and scientific, doesn’t it?). If, after about a year, the patient has shown sustained improvement for quite a while, we can talk about slowly tapering medication. It is always a bad idea to go “cold turkey” with an antidepressant, since it takes the brain some time to establish a new neurochemical “normal.”


So, if you have been hounded by the black dog for at least two weeks and have experienced loss of energy, loss of interest in things, and disrupted sleep or appetite, it may be time to seek professional help. If you don’t know where to look, start with your family physician or primary care provider. First, your primary care provider will try to determine if there is some medical reason for your depression, such as hypothyroidism or some other disease. Once all possible medical factors have been ruled out, your PCP may refer you to a psychiatrist, psychologist, therapist, or counselor. Don’t know the difference between those four mental health professionals? You will in about a month…after my next blog comes out. Meanwhile, if you suffer from depression, just remember that there’s always hope: with proper treatment, the black dog can always be tamed.