Depression

Depression

Fighting through
the Darkness

Betsy can't wake up. She smoked and paced until 4:00 in the morning and now, at 11:00 a.m., she's fast asleep.

Her children--Karen, 5, Kevin, 10, and Jennifer, 12--are used to being on their own. They know it's up to them to make breakfast, do dishes, let out the dog, get dressed and get to school. They know that they can't count on Mom a lot of the time. Dad is usually away on business, so there won't be that ride to the mall, that shoulder to cry on, that game of cards. And they know that, as much as she may love them, Mom often doesn't have the energy to show it. It's all because Betsy is too depressed.

Nearly 12 million American men and women like Betsy experience depression in one form or another every year. Women are twice as likely as men to get it, but they're also more likely to get rid of it, says Frederick K. Goodwin, M.D., former director of the National Institute of Mental Health in Bethesda, Maryland, and now director of the Center on Neuroscience Behavior and Society at George Washington University in Washington, D.C. That's because even though hormones and other biological factors, as well as cultural influences, make a woman more vulnerable to depression, her tendency to reach out to others and to seek professional help frequently gives her the resources to fight off the illness before it can become destructive.

"Men often get caught in the 'stiff upper lip' syndrome," says Dr. Goodwin. "Women don't. This is one of the reasons depressed men are three to four times more likely to commit suicide than depressed women."

What's more, women of the so-called Baby Boom generation have an additional advantage when it comes to beating depression, adds Dr. Goodwin: their attitude. While the number of cases of depression in men and women has doubled in recent decades, the change in the roles and attitudes of women in this group is probably why the earlier three-to-one predominance of women in the depression statistics is now down to two women to every man.

"It's no coincidence that the change in women's depression coincides with a time in which women have more power in society, more independence, more autonomy, more control and more self-esteem anchored in significant, meaningful, recognized achievement," says Dr. Goodwin.

These women have taken charge of their lives, he adds, and as a result, they're less likely to suffer from depression.

An Illness of the Brain

Most of us have experienced gloomy moods that may be lifted by a walk with the dog, an appointment with the hairdresser or a romp in the sheets. But real depression--what doctors refer to as clinical depression--is actually a serious illness caused by a genetic flaw in our brain's chemical "fight or flight" system, along with some heavy-duty stress.

"Clinical depression is no different from an illness of the heart or the pancreas except that the symptoms are mostly behavioral," says Dr. Goodwin.

Women who are depressed act in the grief-stricken way anyone acts when they've lost a job, moved away from a community or experienced the death of a loved one. "With any of these kinds of losses, people initially have intense sadness and little interest in anything," says Dr. Goodwin. "They are totally distracted from living. They feel helpless and hopeless, maybe even a little bit guilty for what they didn't do or could have done in a particular situation.

"They may also have some of the physical signs of depression--trouble sleeping, waking at night, heaviness in their arms and chest, loss of appetite. And they may get obsessive about things. People who are experiencing grief, for example, frequently try to contain their pain by focusing on small details of things, including the rituals of death--planning the funeral procession, arranging for a memorial service, ordering food for a wake.

"But the difference between a grief reaction and depression is that the grief reaction is time-limited in its severity," says Dr. Goodwin. "Even after a few days, a normal person will begin pulling out of her grief. She'll begin to look for distractions. She'll start dealing with the bank, the insurance and Social Security. She'll do what needs to be done."

On the other hand, a woman who is experiencing depression will frequently get worse. She'll become more withdrawn, negative thoughts will fill her mind, and she'll begin to blame herself for everything that goes wrong in her world.

"Trying to think will become like trying to walk through molasses," says Dr. Goodwin. "And her sadness will intensify into really psychic pain that goes on day after day, week after week, month after month."

The Descent into Darkness

Depression can be triggered by an event or a series of events that shakes people to their very core and makes them feel helpless, says Dr. Goodwin.

The death of a young child, learning you're infertile, losing a job--all these are major adult life stresses that can send women hurtling toward the darkness of depression.

But what determines who will actually drop into the abyss and who will not seems to be something of a family matter. No matter how "strong" you are as a person, no matter how take-it-on-the-chin you may be, whether or not you get depressed may depend less on your strength of character than on two things that are beyond your control: your genes and your childhood.

"Genetic vulnerability is the single biggest predictor of who is going to get clinically depressed and who is not," says Dr. Goodwin. "The brain mechanisms that go awry in depression are the ones programmed by the brain to control the so-called fight-or-flight reaction." In someone who's vulnerable to depression, the genetic program is flawed. It has no brakes. So once some stressful event triggers the fight-or-flight reaction, there's nothing to turn it off. The result is a woman who can feel restless, edgy, irritated, depressed and exhausted, all at the same time.

The second biggest predictor of depression is whether a person had a profound childhood experience such as physical or sexual abuse, the death of a parent or perhaps even just a parent who wasn't emotionally able to meet the child's needs. Scientists are still trying to figure out all the different types of loss that might make women more susceptible to depression, says Dr. Goodwin.

But complicating the issue of who does and does not become depressed are a woman's biology and her hormones.

Biologically, we have the capacity for a more powerful fight-or-flight reaction than men do, says Dr. Goodwin. That's because ounce for ounce, we can pour out far more adrenal hormones--the major fight-or-flight chemicals--than any testosterone-loaded male.

As for our hormones, estrogen and progesterone attach themselves to sensitive tissues in the brain, Dr. Goodwin says. But the levels of these hormones are always changing--most dramatically in puberty, at the onset of menstruation, immediately after childbirth and after menopause.

That may be why we hear so much about "adolescent melancholy," "postpartum blues" and "empty nest syndrome." Women's hormones do not cause depression, says Dr. Goodwin, but they do exacerbate any underlying genetic vulnerability.

En Garde

Although a woman's biology and hormones combine to put her at increased risk for depression, mild episodes of depressive illness can actually be prevented before they get out of control and turn her life upside down.

The key is to recognize the fact that you're beginning to feel depressed before the disease actually drags you under, says Gillian Kaplin Adams, M.D., a family physician in Baltimore who has studied depression. And here's how she suggests you do it.

Watch for clues. One of the first warnings of depression is a change in how you think and feel about your world. So watch yourself for sweeping generalizations in which everything's fine or everything's awful and nothing's in between, says Dr. Adams.

"I should" and "I should not" statements--as in "I shouldn't have yelled at my son" or "I shouldn't have had that cherry pie"--are also red flags that your thinking is beginning to be affected by depression. Most people would say "I wish I hadn't yelled at Joe" or "I wish I hadn't had that cherry pie." So if you constantly find "I shoulds" popping up in your conversation, it may be a signal that you're becoming depressed.

Other clues: all-or-nothing condemnations ("I'm always wrong"), minimizing your successes ("It wasn't anything"), magnifying other people's successes ("That presentation was so terrific no else will ever match it"), negative labeling ("I'm a loser") or using emotional reasoning in which your feelings become facts and the real facts don't matter ("I feel that you're having an affair, so don't bother telling me you're not.").

Listen to friends. When friends start to say things like "Gee, you seem down," or "Have you lost weight?" or "Why haven't you called?" or "We haven't seen you for a while," there's a good chance that you're falling into depression, says Dr. Adams.

Tune in to your feelings. Once a day, sit down, tune in to how you feel and write it down in a diary, says Dr. Adams. Then periodically check the diary for the symptoms of depression. When you start to see that you're feeling increasingly restless, tired, hopeless, worthless, guilty, sad and/or irritable, schedule an appointment with your doctor.

Staving It Off

Studies indicate that 80 percent of women who have one bout of depression will have another. So once you suspect you're beginning to get depressed, says Dr. Adams, try to prevent the illness from taking hold with these strategies.

Exercise. "A lot of people who are getting depressed feel incredibly tired," says Dr. Adams, so they may not feel like using what they think is their last bit of energy to exercise.

"But I find that if they can just get out and get going, they really end up feeling better." Experts don't know why exercise helps, but they do know that it can boost production of endorphins--chemicals in the brain that make us feel pleasure and fend off pain. It doesn't matter what kind of exercise you do, Dr. Adams says. Walking, biking, swimming or anything else is fine.

Set a realistic goal. One way to get up and moving is to set achievable goals, says Dr. Adams. With exercise, for example, you can decide to walk a half-mile a day for the first week, three-quarters of a mile for the second week and a mile for the third. Set a slightly harder goal each week until you're working out for a minimum of 20 to 30 minutes three times a week.

Reward yourself. "Don't take the little things lightly," says Dr. Adams. Once you reach whatever goal you've set, pat yourself on the back and treat yourself to something special.

Break out of isolation. Friends can save your life, says Dr. Adams. Tell your friends that whenever they suspect you're isolating yourself from the world, they should come over and drag you out to dinner, a movie, a park, a play, a walk--anything at all. Afterward they should point out what a good time you had.

Stay away from alcohol and nicotine. Alcohol can literally throw you into depression by depressing the central nervous system, while nicotine, which accelerates your heart rate, can aggravate that jittery, edgy feeling some women get right before or during a depressive episode, says Dr. Goodwin.

Get counseling. "Regular psychotherapy in which women come to understand where the depression is coming from and whether it's related to how they deal with life is important," says Dr. Adams. Therapy can uncover both past and present problems that may be contributing to your illness--an abusive parent, a domineering spouse or a destructive work environment. And once you've identified anything that exacerbates your vulnerability to depression, you're on the way to blocking its effects. If you don't know of any therapists, ask your family doctor for a recommendation.

Defeating Depression

Among people who go for help, 80 percent may be successfully treated, says Dr. Goodwin. Mild to moderate depression usually responds to a short, six- to eight-week course of focused therapy and/or medication. Moderate to severe depression generally requires medication, often in combination with brief psychotherapy.

Most drugs used to treat depression fall into one of three groups: monoamine oxidase inhibitors (Nardil), tricyclic antidepressants (Ludiomil) or serotonin uptake inhibitors (Prozac). All manipulate levels of brain chemicals to bring your mood back to its normally balanced state. One of the most popular--and controversial--drugs is Prozac, which makes more serotonin, the calming chemical messenger, available to your brain. The controversy stems from the fact that the drug is such an effective mood elevator that some doctors are at times prescribing it for people who simply want more upbeat personalities.

"In women who have moderate to severe depression, 65 percent will respond to the first drug they're given," says Dr. Goodwin. "That is, over the course of about four to six weeks they will return essentially to normal. But not everybody will respond to the same drug. It's like antibiotics. Some people will respond to one, others to something else. So if you don't respond to one medication, it's important not to give up but to go to a second drug. In this case, the rate of success of the second drug can reach 85 percent.

"The 15 percent who are still depressed may respond partially, so they're not as depressed as they were. But this 15 percent also includes women who have chronic life situations--a lousy marriage, being in a self-defeating situation at work or substance abuse--that's complicating treatment."

Even in this situation, however, the medication will frequently relieve enough symptoms so that the woman can mobilize some energy.

"The drug isn't going to fix a woman's life," says Dr. Goodwin. "But it can restore her capacity to deal with it."