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1. Why did you write Undoing Depression?

Despite the recent avalanche of books and personal accounts of depression, there is not much available that addresses the issue of preventing depression. The emphasis is too often focused on treatment after someone has hit rock bottom. There is a sense that depression is something that happens to you without warning. I disagree. I think there is a warning - that people do lead a depressed lifestyle before they feel depressed - and that people should be encouraged to believe there is a lot they can do to avoid hitting bottom and to make their recovery much faster and more effective. And because of my own personal experience with depression, I feel a strong desire to help prevent people from suffering what my family and I have gone through. Above all, I wanted to give people hope. Hopelessness is a symptom of depression; but there is good reason to be hopeful because 80 to 90 percent of cases will recover if they get proper treatment.

2. Is the incidence of depression increasing?

Depression is certainly increasing. It is no exaggeration to call it an epidemic. At any given time, 20 percent of the population - one in five Americans - are suffering from some form of depression. Take the phone book and start with the letter A. Go on through to the end of the E's. That's how many people from your community are clinically depressed right now. The best research suggests that more people are depressed, more of the time, more severely, and starting earlier in their lives, than ever before.

People born after World War II are more likely to develop depression, and are likely to develop it at a younger age, than the previous generation. "Baby boomers" seem to be at particular risk.

This is not merely a phenomenon of a growing awareness of this disease, but a true growth in hard numbers. Nor is it only a phenomenon of American, or even Western, culture. A recent study comparing incidence of depression in countries around the world found that for each successive generation, depression was likely to begin at an earlier age and that over the course of a lifetime, the risk of depression increases.

3. Do you think there are a lot of people walking around depressed who don't even know it? How can they be helped?

Absolutely. Something that touches me deeply at our clinic is the large number of people who don't know they are depressed. People call us for help not because of subjective feelings of depression, but because something is going wrong in their lives: their children won't listen, there is a marital problem, they are having trouble at work. It doesn't take much digging to find that the caller has been depressed for some time - the family problem, the job problem, is a manifestation, not a cause, of the depression. There are millions of people like this. They may go to their physician for aches and pains, sleeplessness, lack of energy, and they get a useless prescription, medical procedure, or worse, they are dismissed as hypochondriacs.

We need to do much more about educating the public about depression. Depression is a disease, but the word disease make us think about infectious diseases. Depression is more like heart disease - it develops gradually over time. Both are caused by a complex set of factors. Genetic and biochemical factors may determine a different level of stress for each of us that, once reached, puts us over the edge into depression. Childhood trauma, stress, and loss may bring us closer to the edge.

4. How has recent media attention affected the public's awareness of this disease?

I certainly don't think the observed increase in depression is due to media attention. There have been more brave individuals - William Styron, Mike Wallace, Joan Rivers, Kay Jamison, to name a few - coming forward to talk about their own depression, which is helping to reduce the stigma. But depression doesn't receive nearly the media attention it deserves. It is the second most costly disease there is to American society - just behind cancer. Depression is a scary subject for most people and we try to deny its existence. It is difficult to get the media to pay attention.

5. Why are more children being diagnosed as depressed?

This is a matter of better observation, not necessarily a real increase. Until 1980, most mental health professionals were guided by a theory that said, in essence, depression is caused by a punitive superego; people don't develop a superego until adolescence; ergo, pre-adolescents can't suffer depression. Though it sounds silly today, that is the way the mental health community thought.

Depression is difficult to recognize in children. Estimates are that 10 percent of children will suffer a depressive episode before age 12. Children usually don't have the capacity to step back and recognize that the way they are feeling is not normal for them. The symptom picture of depression in children and adolescents is also confusing because they cannot express their feelings as directly as adults. Irritability is a key indicator. Children may seem easily frustrated, cranky or moody. Boys may simply appear unusually angry or sullen. Other signs may be a change in appetite or energy level; sleeping a great deal more or less than usual; a drop in school performance; excessive worrying; or a loss of interest in things or activities that used to give pleasure. Untreated, depression can be permanently devastating to children.

6. How does depression impact on the family?

Depression is very tough on family members. Usually there is not a dramatic change in personality but often a slow, insidious process which makes it difficult to recognize that something is really wrong. As friends or relatives, we may feel uncomfortable around the sufferer. Living with someone who is depressed can be one of the most helpless-feeling experiences there is. We want to help the sufferer, but we don't know how; often it seems that whatever we do makes things worse. The person's problems do not respond to good advice or common sense. Sometimes out of frustration we get angry, and feel guilty afterward.

7. How can loved ones help a depressed person?

What the depressed person needs most is understanding, patience and acceptance from those close to him. I have a self-help group that meets every week. We have put together a fine list of how loved ones can help:

  • Try to be considerate, thoughtful, and empathetic. If your spouse had a broken leg, you would expect that their abilities and energy would be restricted, that they would be in pain, and that they can't heal themselves more quickly just because you want them to. Think about depression the same way.
  • Don't be provocative. Every relationship has the little hot buttons that can start a fight at any time. Dirty socks on the floor, the remote control misplaced, the car low on gas. You know what your partner's buttons are. Don't push them while he/she is in a depressed state.
  • Small acts of kindness are appreciated, and do help, even if the recipient doesn't reciprocate. When I retreat to bed, my wife makes a point of breaking in to kiss me good night. Even though I sometimes don't act very glad to see her, I would feel worse, lonely and unloved, without her attention.
  • Easing your partner's burden in small ways can help a great deal. Offer to do the shopping, empty the garbage, do the laundry, take the kids out for pizza. It communicates more than words the feeling that you understand how difficult these mundane chores can seem at times.
  • "Advance directives" can be a contract loved ones arrange while the sufferer is not depressed, describing what to do when depression sets in. It can be in stages: stage 1 - leave me alone; stage 2 - be kind, patient, and attentive; stage 3 - insist I call my therapist; stage 4 - take me to the hospital. One patient loses her ability to see color when depression sets in. From experience, she has learned to let her husband know when this happens, because she won't let him know when it gets worse.
  • Take the trouble to educate yourself. Learn all you can about depression. Be willing to talk to your friend's therapist. It is amazing how seeing information in print, or hearing from an authority, can change your perspective. Learning the facts helps you help your friend, and also shows that you care enough to take some trouble.

8. Do you believe that therapy or medication is the solution?

Therapy and medication are the solution. I would advise anyone seeking treatment to be open to both. Medication can help more quickly than therapy alone, and can help to prevent the out-of-control mood swings that will come during recovery. Therapy can help us resolve the problems that led to the depression and help us learn how to prevent future episodes. Research shows that medication and therapy together are more effective than either by itself. Some people do recover on either medication or psychotherapy alone, but I'd really recommend being open to both. After recovery, sometimes a maintenance dose of medication or a periodic check-in with a therapist is helpful.

9. How does depression differ from manic depression?

Manic depression, or bipolar disorder, seems to be a different sort of animal. It strikes one percent of the population. It is more genetically linked than other forms of depression and it responds uniquely to a single medication - lithium. Other forms of depression don't respond to lithium and don't experience the manic highs that are characteristic of manic depression. In individual cases sometimes it can be difficult to differentiate between depression and manic depression immediately. You have to observe the course of the disease over some period of time.

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