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Eleanor, 40, is a bright, attractive, well-educated Denver stockbroker who has struggled with feelings of overwhelming sadness
for at least 25 years. "I can't remember when I wasn't depressed," she says today. Although her depression probably
began in childhood, it was in college that she realized something was very wrong. "I tried Rolfing, transactional analysis,
meditation. I cut out coffee, smoking, and alcohol. I went on vegetarian diets, juice diets, and fasts. I kept trying all
these alternative therapies because I thought that something should help the way I felt." How she felt, she says, was
miserable. "My body ached, the way you feel right before you get the flu -- lethargic and hurting. That's why I smoked
dope and drank alcohol; I was trying anything to feel better. But nothing worked." Then, in her mid-thirties Eleanor
was injured in a car accident, and her depression deepened. "I cried all day long. I would cry at every TV show -- even
'Gunsmoke' and 'I Love Lucy'," she recalls. "I kept asking doctors why I was so depressed." Eleanor's psychologist
finally became angry: "One day she snapped at me," Eleanor recalls, "and she said, 'Do you want me to send
you to a psychiatrist so you can take pills?' She said it as if taking pills was a moral failure." After another six
months of fruitless talk therapy, Eleanor finally did go to see a psychiatrist, who did indeed prescribe an antidepressant
for her depression -- one of the most serious cases he said he'd ever seen. After her doctor tried three or four different
medications, Eleanor's depression finally responded to a combination of Paxil and lithium. "I feel as if I've been ripped
off my entire life because I was depressed for so long," Eleanor says. "Now I have my sense of humor back. I feel
great. I feel normal."
Many people have stories similar to Eleanor's. Depression is far more common than most people realize: Two out of every
ten of us are clinically depressed. As many as 23 percent of all adult women have had one major depressive episode in their
lifetime. The tragedy is that although so many people are struggling silently with crushing misery, so few get help. There
are 100,000 Eleanors in this country who haven't been correctly diagnosed and who aren't receiving treatment that could mean
the difference between life and death. Even today, too many Americans are intolerant of any type of mental illness -- especially
depression, which is often dismissed as some sort of moral failure. In a recent poll by the National Institute of Mental Health,
nearly half of all respondents stated that depression was a "personal weakness" -- certainly not a health problem.
It was precisely this intolerance that drove a noted Pennsylvania jurist to try to cover up his depression by having his employees
fill his Prozac prescriptions -- a felony for which he will probably pay with his job. He finally confessed to the subterfuge
because he said he decided that worse than being branded "depressed" was being labeled a drug trafficker. Depression
reaches from the poorest inner-city homes to the loftiest palaces. Sylvia Plath, Dick Cavett, Georgia O'Keeffe, Mark Twain,
Virginia Woolf, and Abraham Lincoln all wrestled with depression. "I felt a kind of numbness, an enervation," recalls
William Styron in his book Darkness Visible: A Memoir of Madness, an account of his Herculean struggle with major depression.
"Mysteriously and in ways that are totally remote from normal experience, the gray drizzle of horror induced by depression
takes on the quality of physical pain."
Emotions: Do you feel ineffably sad or cry a great deal? Appetite/weight: Have you gained or lost weight? Do you binge
or overeat? Sleep: Do you have chronic insomnia or excessive sleepiness? Are you tired all the time, regardless how much sleep
you get? Anger: Do you experience outbursts of complaints or shouting? Have you been feeling resentful and angry? Outlook:
Have you lost interest in hobbies or activities that you formerly enjoyed? Libido: Have you lost interest in sex? Self-esteem:
Do you feel worthless, unattractive, inappropriately guilty? Concentration: Do you have a hard time concentrating? Are your
thoughts muddy or foggy? Anxiety: Do you brood, have phobias, delusions or fears? Restlessness: Do you have trouble sitting
still? Muted affect: Do you have slow body movements and speech? Suicide: Have you thought you'd be better off dead?
A diagnosis may begin with a brief family history combined with a medical workup, including tests to rule out under active
thyroid, mononucleosis, anemia, diabetes, adrenal insufficiency, and hepatitis. Your doctor will want to know about any medications
you've been taking, since a number of prescription drugs can cause depression. While you're at it, you might also let your
doctor know about any vitamins, herbal medicines, amino acids, diet supplements, or recreational drugs you have taken.
Major Depression
While symptoms differ from one person to the next, major depression is almost always characterized by general feelings
of sadness and a total loss of pleasure in things that once brought you joy. You might also have sleep and eating problems
or a sense of worthlessness. Perhaps you're no longer interested in sex, you're feeling apathetic, or you have suicidal thoughts.
According to the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders, published by the American Psychiatric
Association, a typical episode of a major depressive disorder lasts at least two weeks and includes most of the symptoms listed
in the section above, "Are You Depressed?" Other common signs of depression may not be found in medical journals.
"I ask patients if there are cobwebs in their house," says psychiatrist Andy Myerson, M.D. "If patients aren't
bathing, if their house isn't clean, if they can't get out of bed -- that's a good indication that they're depressed."
Many people in the midst of depression agree with him. "If I have to fight my way to the bathroom and I haven't opened
my mail," Violet laughs, "I know I'm in trouble." It is possible, however, to have a major depression and not
feel particularly sorrowful, sad, or hurting. You may instead have eating problems or problems sleeping, remembering, concentrating,
or making decisions. Only a mental health expert can diagnose a depression that is hiding as some of these symptoms.
Dysthymic Disorder
Not everyone gets depressed in the same way. If you have a major depression (known as unipolar or clinical depression),
your feelings of misery may be interrupted by periods when you feel okay. On the other hand, if you have a chronic minor depression
(now called "dysthymic disorder"), you'll feel mildly depressed all the time; this constant low-level depression
can last for years at a stretch. You may even have both types of depression at the same time. "My problem with dysthymic
disorder was characterized by fatigue," says Aguri, a 45-year-old psychologist who lives in New York. "By the afternoon,
I became very tired and less clear in my thinking; I had to take a nap every afternoon or I couldn't work in the evening."
Burdened by mounting job responsibilities, he finally sought help from his physician, who suggested the tricyclic Elavil.
"It really helps," Aguri reports. "When I lower the dose or stop taking it, I can't sleep well and I get very
tired. It helps improve my energy level." Called depressive neurosis in the 1950s and depressive personality in the 1970s,
dysthymic disorder is a persistent mild type of depression affecting as many as 3 million people. In order to be diagnosed
with dysthymic disorder, you must have been depressed during most of the past two years, with at least two of the following
six symptoms: low self-esteem poor appetite or overeating insomnia or increased sleeping difficulty concentrating or making
decisions hopelessness fatigue or low energy This type of mild depression can be misdiagnosed as borderline personality disorder,
which in itself does not respond to antidepressants. Dysthymic disorder, however, can be treated with antidepressants.
Double Depression
If you've been struggling with a long-term dysthymic disorder and suddenly experience a major depression, your psychiatrist
will diagnose a "double depression." Many doctors have successfully used the new SSRIs, including Prozac, in such
cases to treat the dysthymic disorder and prevent the return of major depression. Controlling this combination of depressions
may require a slightly higher dosage.
Atypical Depression
If you find that you continually crave sleep, food, or sex over a period of two weeks or more, you may be developing what's
called "atypical depression." Most depressed people don't sleep or eat enough, and many lose weight, but people
with atypical depression gain weight and sleep too much. They're also anxious and extremely sensitive to their environment
and to rejection. Atypical depressions may be disguised as bulimia, anorexia, compulsive overeating, oversleeping, addictions,
or impulsiveness. While some of these symptoms are also found in major depression, they aren't as severe and don't last as
long. If you have an atypical depression, you may feel that your phobias, symptoms, or hysterical feelings are more troublesome
than your depression, but, in fact it's the depression that causes these symptoms. Experts don't know why atypical depression
appears in many ways as the polar opposite of major depression or why it's more common in women than men. But we do know that
without treatment, the symptoms will probably get worse. In the past, patients like this responded best to one of the MAOIs;
today, the SSRIs (including Prozac) appear to be just as effective.
Sub clinical Depression
If you have only two or three symptoms of depression as opposed to five or more, your doctor may diagnose a "sub
clinical depression." If you're so diagnosed, it is likely that you've never sought mental health treatment, since you
can probably function fairly well despite low self-confidence, timidity, lack of interest, sadness, emptiness, or fatigue.
Psychotherapy alone may not solve these problems if they are of long standing, but many people with sub clinical depression
respond well to Prozac or another SSRI in conjunction with psychotherapy.
Other Forms of Depression
The symptoms of psychotic depression may include delusions of guilt, serious medical illness, and a feeling of deserving
punishment for imagined mistakes. There may also be auditory hallucinations or other delusions. The melancholic type of depression
includes lack of the ability to have even fleeting good feelings, a worsening of mood in the morning, early morning awakening
(between three and four o'clock), more than 5-percent weight loss per month, agitation or lethargy, loss of interest in all
activities.
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