“Depression,” like “heart attack” is a generalized term covering a variety different conditions with a final, shared path of feelings of sadness and grief coupled with symptoms, such as tearfulness, lack of appetite, insomnia, weight loss, and feelings of despair, hopelessness and sometimes worthlessness. These can range from mild to severe.
Like elsewhere in medicine, the first step in treatment is to make an accurate diagnosis. To that end “depression” is seen in three forms in my experience
A - accidental or situational
Grief, and “depression,” is an entirely natural, psychological response to important losses. Such grief, temporary in nature, can be accompanied by some biological features as above. But there is always an initiating stress and perfectly understandable, “normal” reaction to loss, most often to death of a loved one or some other significant loss.
Such grief can be severe, and sometimes prolonged. But humans are generally resilient persons and time itself is a good healer. In some instances, psychotherapy and/or grief counseling is helpful, and in all cases support from families and friends, and in many cases, church and faith, is uplifting and
helpful. Some of the somatic symptoms can be alleviated with anti-depressants on a temporary basis, along with anti-anxiety medications or sleep aids. In some severe cases, brief hospitalization may be necessary.
In most cases, the mood gradually improves, and the loss is absorbed with resiliency and perspective.
B - biological and neurochemical
In other cases, the depression occurs without precipitating incident in otherwise well-adjusted persons. For example, a well-adjusted, successful accountant gradually begins to have insomnia and early morning awakening. There is at first a vague feeling of sadness and sometimes tears. He begins to doubt his work and becomes convinced he has made many errors on client’s tax returns to where some will go to jail. He stops eating normally and loses weight. He sometimes considers himself so imperfect he considers suicide. There is a pervasive sense of sadness and worthlessness. Family members are astonished at the complete change in personality with such suddenness and no clear precipitant. It feels to them like an illness.
Such cases, which often begin later in life (“involutional depression”) in otherwise well-adjusted men and women, indeed are due to “chemical imbalance,” or more specifically neurochemical imbalance. The cause of the imbalance, like
many other illnesses of other organ systems, is not clear and not directly related causally to life events.
Such depression typically is treated successfully with anti-depressants of which there are a wide variety now. Finding the right anti-depressant for the right patient in the right dose is, like elsewhere in medicine, as much an art as a science.
Most patients respond to treatment satisfactorily. About 25 percent, however, remain refractory to treatment and require more intrusive treatments, such as electro-convulsive therapy (ECT), rTMS (rapid transcranial stimulation) or deep brain stimulation.
C-constitutional or way of life
For some individuals pervasive pessimism, dark mood and ‘half-full’ mentality seems to be a way of life. Joy is infrequent and self-doubt pervasive. This form of chronic depression is less common than A or B above, is psychological origin, and is more of a personality disorder than situationally precipitated or a neurochemical imbalance. It may be a reaction to a whole series of difficult life circumstances but sometimes seems almost an inherited, constitutional, way of being. Medications are not particularly useful. In some ways, it is the most difficult form of depression to treat, but psychotherapy over the long run often is useful.
Overall, I have been impressed with resiliency and capacity to heal of the human body whether the illness is organic or psychological. Watching the accountant resume his life and practice with confidence, joy and equanimity is as gratifying in psychiatry as any other specialty. The search continues for even more effective medications and other treatments in psychiatry. With successful outcomes more prevalent, reaching out for help sooner when needed is occurring and like with other illnesses the sooner the intervention the better the outcome.