Like any organ in the body the brain will not work properly if enzymes needed for its functioning are in low supply. In the brain these are called neurotransmitters because they allow the transmission of the impulses or messages from one neuron cell to the next. Without enough serotonin, for example, the messages lag or simply don’t make it. The effects of this insufficiency are experienced throughout the brain, not just in the areas affecting mood. There are cognitive and physiological effects as well. Put together these effects constitute what we identify as depression. The term itself causes confusion, however, as most of us suffer from periods of sadness or feeling down when dealing with normal life experiences: loss of a loved one, financial difficulties, or family and relationship problems, for example. These dips in mood and confidence are usually short-lived as we rally and learn to strategize and deal with our issues.
What is meant by the term depression clinically, however, entails a much broader canvas. Someone who has never experienced the devastation of a clinical depression cannot understand or judge what may be happening within their friend or family member who clearly is suffering. Advice or admonitions may be given: get over yourself; just get on with things; we all get down sometimes but we don’t let it get the better of us. Already overwhelmed with a true mental (ie, brain) illness, the sufferer must handle also the shame placed on them by others and by their own inner fears that they are operating out of moral weakness.
When a client presents herself clearly experiencing a generalized malaise, or suffering from severe anxiety and/or irritability, a good beginning is to go through the list of indicators for a diagnosis of depression: Difficulties with memory or concentration? A sense of being overwhelmed by ordinary tasks? Insomnia or over-sleeping? Low energy? Under- or over-eating? Physical pains related to tightening of muscles, especially in the chest or abdomen? Low self-esteem? A sense that life is just too hard and that one will be better off when it is over? Active or passive thoughts of suicide? Crying easily for little cause? A somewhat pervasive sense of sadness, anxiety, or irritability – sometimes alternating with one another? Anyone acknowledging a significant number of these symptoms ought to be made aware that she is likely suffering from the complex syndrome of depression. A visit to her doctor for a physical examination and discussion of her symptoms is important. Other conditions can trigger depression or be masked by it. If no other physical ailments are found to possibly explain the client’s depression, anti-depressants can be prescribed by her doctor, especially if the symptoms she is experiencing are inhibiting a healthy enjoyment of her daily life.
Our clients teach us lots of things about ourselves and about areas that we have little knowledge or experience with. About 20 years ago a young woman came to see me who was truly felled by acute depression. She was on a disability leave from her job. At least 20 of every 24 hours were spent in her bed or on her couch. She simply could not function in her day-to-day life. About the same time that she started to see me her GP prescribed anti-depressants. I was dubious about the wisdom of this approach as I had learned my trade within a therapeutic community that was aggressively anti-medical model. In the 1960s while this group was in its formative phases it is true that medicine had few effective solutions for mental health problems. Following a psychodynamic psychotherapy tradition and experimenting with newer, body-based therapies, the community was never able to expand toward a rapprochement with research into the functions of the brain and newer pharmacological directions that were beginning to emerge.
It was with astonishment then that I witnessed the transformation in my client’s energy levels and general competence over the next several weeks. Her doctor had recommended two books to her – books which I quickly acquired and read. One was “Listening to Prozac” by Peter Kramer, a psychoanalytically trained psychiatrist who as a resident had had a revelatory experience with a patient on his ward similar to my own. It had revolutionized his thinking, allowing him to operate on the two fronts of medicine and “talk therapy.” His book gives an overview of the symptoms of depression, some historical information about the development of psychotropic medications, and examples from his own practice of ways that the medications changed the lives of his patients in somewhat surprising manners.
The other book was provocatively titled, “You Mean I Don’t Have to Feel This Way?” by a writer named Charlotte Dowling. When her adult daughter was stricken with a major depression not dissimilar to that of my own client, Dowling put her research skills to good use, learning all that she could about the illness and its possible treatments. She connected with some of the leading researchers at the time, picking their brains for whatever was available to help her daughter. Placed on one of the newly developing SSRI medications, her daughter was brought out of her deep depression and was able once again to resume an independent existence. Dowling then set about writing her book, giving information and hope to many who until this period had few options available to them.
Since these books were published there have been many advances in understanding and maping brain dysfunction. For example, research has shown that considerable stress of any nature in early development can result in chronically low levels of serotonin, leaving a child vulnerable to later cycles of depression. Long term studies indicate that the best treatment for depression is a combination of medication and psychotherapy. As Kramer found in auditing the subtle effects of medication on his patients, restoring optimum neurotransmitter levels in the brain gave what he called "a floor" to his patients. When stress or crisis occurred, rather than falling as it were through to a place of panic or despair, they were more able to absorb the impact and to deal more competently with the situation before them. Of course people are often reluctant for many reasons to take anti-depressants, but that is another, rather lengthy conversation.
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