It’s normal to feel depressed following the death of someone you love, the loss of any important relationship, or, as Hamlet said, ” The slings and arrows of outrageous fortune ” and “The heart-ache and the thousand natural shocks that flesh is heir to.” Scales that rank the stress of life change events place death of a spouse at the top, followed by divorce, marital separation, death of a close family member and imprisonment.
Depending on the number and severity of life change events, it is possible to predict the likelihood of developing some stress related illness. Following the death of a spouse, mortality rates in the survivor soar over the next 6-12 months and remain high for the next few years, particularly in widowers. The dilemma for physicians in this and other situations is how can you tell when depression is abnormal? And if it is, how should it be treated?
To begin with, strictly speaking, depression is not a distinct disease. It is merely a collection of certain symptoms that can have varied causes and therefore require different treatments. Unlike any other disease, there are no physical signs, blood, urine or saliva tests, x-rays and sophisticated imaging studies (MRI, CTT, PET scans) or biopsy results to confirm a diagnosis. Even a thorough autopsy with microscopic examination of brain tissue will fail to show any distinctive abnormalities.
As emphasized in prior Newsletters and e-magazines, there has been little if any progress in the diagnosis and treatment of depression (or other mental disorders) over the past 200 years. That helps to explain why we have such a large list of different therapies for depression, including over 20 serotonin and combined serotonin-norepinephrine-dopamine reuptake inhibitors, monoamine oxidase inhibitors, tricyclic and tetracyclic drugs, membrane stabilizers, lithium and hormones. There are also numerous non prescription vitamins, herbals (St. John’s wort, valerian), nutraceuticals (fish oils, SAM-E), melatonin and stimulants, as well as acupuncture, visual imagery, therapeutic touch, stellate ganglion block, U-V light, hypnosis, psychoanalysis, cognitive-behavioral therapy (CBT), emotional freedom technique or “tapping” (EFT), eye movement desensitization and reprocessing (EMDR), companion dog therapy, meditation, music, yoga, aerobic exercise, electroconvulsive shock therapy (ECT), transcranial direct current stimulation (tDCS), repetitive transcranial magnetic stimulation (rTMS), cranial electrotherapy stimulation (CES), deep brain stimulation (DBS), vagus nerve stimulation (VNS), and most recently, ketamine (an anesthetic) and scopolamine, used to treat motion sickness.
It is difficult to think of any other illness where there is such a plethora of diverse modalities, each of which has its own proponents based on apparent efficacy in selected patients. The problem is that with the possible exception of U-V light exposure in Seasonal Affective Disorder (SAD syndrome), there is no algorithm to predict which modality will succeed in any given patient.
We do know that there are hormonal differences since women are affected twice as often than men. Depression and other emotional disturbances were previously thought to be related to the monthly (lunar) cycle, hence the term lunatic. Women with PMS and especially PMDD (Premenstrual Dysphoric Disorder) may suffer from depression, post-partum depression is not uncommon, and menopausal depression is so well recognized that involutional melancholia was previously an accepted psychiatric diagnosis. However the treatment for these and all other types of depression is apt to be a drug that boosts serotonin and or some other neurotransmitter.
Such SSRI antidepressants are now the most common prescription medication for Americans age 18-59 despite the fact that no studies show a serotonin deficiency in depression. In addition, these drugs are no more effective than placebos in the vast majority of patients, have serious side effects, including suicide, and are difficult to stop because of severe withdrawal symptoms. As psychiatrist and drug company whistleblower David Healy, author of Pharmageddon, wrote, “The serotonin theory of depression is comparable to the masturbatory theory of insanity.”
Newer does not always mean better. Lobotomy was originally touted as such a breakthrough and safe treatment that many patients opted for a 15-minute “icepick” procedure done through the eyes for only $25.00. The current deplorable situation is only going to worsen as the incidence of depression has been steadily increasing, especially in younger age groups. It is now the leading cause of disability worldwide, and the World Health Organization predicts that by 2030, more people will suffer from depression than any other medical condition.