More than 20 million Americans will suffer an episode of depression or mania during their lifetimes, and one in five American families will feel its impact directly. For these families, Overcoming Depression is the essential resource. Since its first publication in 1987, it has become the book most often recommended by doctors to their depressed patients because it clearly and sympathetically presents state-of-the-art medical information and the solid, practical advice that patients and their families need to participate actively in diagnosis and treatment. Now featuring all-new data on the latest drugs, research, treatment, and medical insurance, it also includes a frank discussion of psychiatric therapy in the era of managed care.

Overcoming Depression, 3rd Edition

By Papolos, Demitri

Quill

Copyright © 2004 Demitri Papolos
All right reserved.
ISBN: 0060927828
About the Illness

The Personal Experience

When we first told friends and people outside the psychiatric field that we were writing a book on depression and manic-depression, we expected polite but lukewarm interest. That wasn't what happened. Instead, one person after another confided to us: "I've had experience with it; my mother and brother are bipolar"; "My grandmother and younger sister were just put on lithium"; and "My adopted son suffers from recurrent depression. . . . I don't know if his real parents had it." These people were stating what clinicians have always observed: depression and manic-depression are very common illnesses and tend to concentrate in families.

Mood disorders are the "common cold" of major psychiatric illnesses, and more than 20 million Americans will suffer an episode of depression or mania during their lifetimes. One in five families will directly feel their impact. Those who have manic-depression will veer from periods of superactivity, manic elation, and grandiose schemes to periods of despondency, immobility, guilt, and inability to experience pleasure or even to think normally. The people who experience these highs and lows have what psychiatrists now call bipolar disorder. Those who suffer recurrent severe depression without the highs are said to have unipolar or nonbipolar major depression. The psychiatric profession groups these mood disturbances under the rubric major affective disorders. At first glance the term "affective" doesn't send the mind traveling, but it's a word philosophers and psychologists have traditionally used for emotion or one's "spirits."

Whatever these disorders are called--affective, manic-depressive illness, recurrent mood disorders, unipolar or bipolar depression--they've been affecting humankind throughout the centuries. Some very familiar individuals figure among the victims: King Saul of the Bible (who needed David's music to soothe his despondency), King George III (the last English king to rule the American colonies), Abraham Lincoln, Winston Churchill, and Theodore Roosevelt. The writers and poets Johann Goethe, Honore de Balzac, Leo Tolstoy, Virginia Woolf, Ernest Hemingway, Robert Lowell, and Anne Sexton suffered mood swings, as did the composers George Frederick Handel, Robert Schumann, Hugo Wolf, Hector Berlioz, and Gustav Mahler. These people are well known and respected, so it may be that the illness fuels a certain kind of drive and creativity. However, a study of their lives would also reveal searing anguish, shattered relationships, psychosis, and even suicide.

Mood changes are hallmarks of the human experience, and mood has a powerful evolutionary value: it regulates our disposition to action and behavior, and keeps us involved in life and yet relatively safe. However, those who are too pessimistic may not realize their potential; someone who is depressed will step back from life and not participate. On the other hand, a person with too optimistic a mood may also place himself or herself at risk; someone experiencing a manic episode can get carried away with an exalted sense of power and self-importance and act impulsively or recklessly. An immoderate mood disposition can cause life to be fragmented, disorganized, painful, and potentially dangerous.

Mood also has a strong influence on the way someone feels about himself. When depressed, he or she often dwells on exaggerated memories of losses or failures, or focuses on the morbid and negative aspects of life to the exclusion of all else. Negative thoughts or perceptions about oneself can erode self-esteem, resulting in an unrealistic sense of worthlessness and the feeling of being a burden to others. A person may experience persistent feelings of sadness and emptiness, become tearful for no apparent reason, or become irritable and hostile.

The depressed person may be slowed down, lack energy, and have fewer ideas. Decisions seem nearly impossible to make, and everyday tasks and challenges become intimidating. Some severe types of depression may include irrational, psychotic, or delusional symptoms. Since these episodes may last for several months or longer, one's morale or self-esteem can become seriously impaired. Prolonged periods of depression can lead to the wish to die and to thoughts of killing oneself.

In contrast to this bleak picture, the person experiencing the "highs" of manic-depression often describes feeling better than at any other time in his life. He cannot understand why anyone would call his experience abnormal or part of an illness. The rate of thinking is markedly increased; one thought after another bursts into consciousness demanding expression. During a manic episode, a person feels more excited, has surges of energy, and describes feeling more active, creative, intelligent, and sexual than he ever thought possible. Sleep seems unnecessary, and he's ready to "take on the world." It is not unusual for a person in a manic state to decide to try to write the great American novel or to embark on audacious and risky business ventures.

The seemingly boundless energy and enthusiasm that are often a part of the manic swing can be infectious at first. Those witnessing a person charged with exuberance and confidence are often quite intrigued. Mania is not a state to be envied, however. Decisions made during a manic high are typically reckless and impulsive. Spending sprees and sexual indiscretions are common, and some people experiencing the disorder find the excess energy and excitement unbearable. They may turn to alcohol or drugs to calm the agitation or irritability. As the manic throttle is pushed, the person becomes more argumentative, intrusive, and insistent about getting his own way. Others around him then become confused, angry, and alarmed.

While some people experience a more controlled state of mania with elation and excessive activity called hypomania, others lose contact with reality as their thinking becomes fragmented, disorganized, and delusional. The person may envision himself as the savior of the world, or he may experience paranoia and respond to others with extreme irritability and anger. In this psychotic stage, the disorder can be confused with schizophrenia. Eventually the manic episode runs its course, though, and the person may be plunged into the depths of depression--surrounded by the shards of his life, career, and relationships.

The person who experiences out-and-out manic episodes alternating with periods of depression is referred to as having bipolar I disorder. The person who suffers very mild hypomanic periods as well as severe depression is said to have bipolar II disorder. There are also some people who experience only the manic highs and little or no depression, and they are referred to as having unipolar mania.

The onset of the first episode of an affective disorder may not always be obvious. Some people have brief, mild episodes infrequently and do not seek treatment or even know that they are ill. Since we all experience periods of sadness, disappointment, and grief, it is difficult to know when a depressed mood becomes a medical condition. While there continues to be debate about this question, it may be useful to conceptualize the state of depression as developing along a continuum from mild to severe.

When a person experiences some major disappointment in a career or relationship, the loss is usually followed by a few days of sadness, withdrawal, sleep disturbance, and anxiety, but it is not long before the normal mood is reestablished and the person regroups and goes on with life. When, however, the depressed mood persists, the isolation from others continues, and the individual loses a sense of pleasure and meaning in life and begins to develop physical symptoms such as loss of appetite, a marked interruption in the regular sleep cycle, and a marked decrease in the ordinary level of activity, these signs signal the onset of a clinical depression. The person has moved across the boundaries that demarcate normal mood fluctuations to a medical condition. (It should be noted that the clinical syndrome of depression can present itself without any noticeable precipitants such as loss or disappointment.)

Typically, episodes of illness are time-limited: they come and go, last from several weeks to several months, and are followed by periods of relatively normal mood and behavior. Untreated, the average depressive episode lasts about four months, and the average manic episode about three months. Periods of depression, however, can last for twelve months or more without remitting.

Not all people who experience a major depression will suffer a recurrence, but psychiatrists are beginning to realize that depression is more recurrent and chronic than originally thought.

Dr. Jules Angst in Zurich found that 70 to 80 percent of patients with an initial episode of major depression experienced recurrence; and data from the U.S. Catchment Area study revealed that patients who have had at least three or more episodes will have an 80 percent chance of relapse within a three-year span of time; that rate rises to 90 percent or higher after 5 years. The lifetime average for depressive episodes is 5 to 7, but as many as 40 episodes have been reported.Continues...

Excerpted from Overcoming Depression, 3rd Editionby Papolos, Demitri Copyright © 2004 by Demitri Papolos. Excerpted by permission.
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