Understanding depression in adulthood


Dr. Rob LEES

Steve Smith, the comic who plays Red Green, claims that depression is the default setting in life. Is he right?

In this space over the past few weeks, my colleagues and I have been attempting to explain various aspects of this malaise known as depression. Carey Christiansen wrote about Dysthymia, a long lasting, low level depressive state. Dysthymic individuals usually get through life fulfilling their expected roles, thinking their lack of enjoyment is normal. Eryn Wicker wrote about depression in the senior years, Marie Amos wrote about depression in childhood, and Dr. Kym Dawson wrote about depression in adolescence. Last week, Eryn covered a form of depression following childbirth, post partum depression. (Yes, that's right, you'll have to call the paper and get these back issues!). My role is to address the issue of depression in adulthood.

How prevalent is depression? The evidence shows it varies from place to place. Generally, the chance that a woman in North America will experience a major depression in her lifetime will vary from 10 to 25 per cent. Interestingly, for men, it is 5 to 12 per cent; about half the prevalence for women. This may have to do with how men process and describe feelings. At any one time, five to nine per cent of women, and two to three per cent of men suffer from depression. This makes it among the most prevalent mental illnesses.

Depression is more than feeling down for a few days. It's feeling down, sad, hopeless, discouraged, and not enjoying most activities, for more than two weeks. Major depressive illness goes on much longer. It often involves disturbance of sleep and appetite, and can lead to a slowing of cognitive ability. Sufferers often can't concentrate or keep information in memory.

In many ways, depression mimics grief, but for one feature. Depression usually carries thoughts of low self esteem, and sometimes suicide, whereas normal grief does not. As well, to complicate the picture, most of us have felt sad, disinterested and down on ourselves at some point in our lives. Therefore it is possible to think, like Steve Smith, that depression is part of the human condition, and not an illness. Clients with depression often berate themselves because they can't seem to get themselves out of it. Self blame is of course part of the illness, and a condition maintaining it.

Depression can range from mild, shorter episodes (measured in months) , to severe, long lasting, disabling illness, (measured in years). It's known that there are biochemical and electrical differences in the brain activity of the depressed, different from the non- depressed. In the last decade medicine has made remarkable strides with medication, and with electrical shock therapy for resistant depressions. Psychology has been making strides as well. Studies indicate that Cognitive Behavioural Therapy (CBT), Interpersonal Psychotherapy (IPT), and Emotionally Focussed Couple Therapy, focussed on relationships and losses, demonstrate efficacy similar to medication, and with longer lasting results. Together, psychotherapy and medication, are considered the gold standard treatment.

One important thing to know about depression is this: it is curable. It is simply a matter of getting the right treatment, delivered by the right person, at the right dosage, at the right time. In other words, what works for one, may not work for another. Exercise, diet, changes in family or work relationships may each prove effective for one person, and not another. Medication may work for some, and not others. The same with counselling. Often a combination of strategies is necessary.

Okay, maybe it isn't simple. In fact, many of the treatments require a good deal of energy and determination, something often lacking in depressed people which is a function of their illness. Even with treatments as straightforward as taking medication, studies in general medicine have shown that most patients fail to comply with treatment as directed. They forget to take it, they stop taking it before recommended, they increase and decrease their dosage, and combine it with foods or beverages that are not recommended, such as alcohol. Given the high cost to our health care system, it surprises me such little attention is given to behavioural medicine to improve treatment compliance.

Often the first major hurdle is getting the affected person, and their family, to accept that what they have is truly an illness. This seems to be a difficult concept to grasp. In my experience, before a person ever gets to a professional, he or she has been through a long period of time when they and their family thought they were lazy, or even faking to get out of something. Even when a physician or psychologist diagnoses it, people may still be unconvinced; coming to acceptance of depression as an illness is often one of the biggest forward steps in treatment.

Complicating matters, there are a goodly number of people with depression who also have substance use problems. At times, the substance use, such as alcoholism, will be the loudest signal that the person is actually having a problem. It may disguise the presence of depression. Similarly, other major life transitions, or medical illnesses may conceal a co-existing depression.

When children or dependent elderly are depressed, it seems more acceptable for family and those around them to intervene as active agents in treatment. In fact, the supportive structure of our social field is often essential to treatment compliance and eventual healing. In the case of adults, it is hard for family members and friends to know how involved to get. In my experience, kinship relations are equally important in adult treatment, as with children. As well, family, friends and work colleagues are often better informants on symptoms and progress.

Steve Smith is wrong. Depression isn't the default setting in life. When I see my grandchild, I see the true default setting - curiosity, wonderment, a desire to grow, accomplish and be connected. When I see people follow through on the right treatment, they get better. Their gifts to life, and their enjoyment of it, return. If you or someone you know fits the profile of depression, it is well worth consulting your physician, or a registered psychologist or clinical counsellor. Feeling Good by David Burns is considered a classic and helpful read on the subject.