9.28 Depression - A Cure

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28. Depression (Update 16 Septr 2021. The below column, search & find for topical reading. 

                                                                    What is it?

Aspects of Depression

Labels of Depression - Its History

  A Practical Explanation of Depression and Causes

Antidepression Medication

What to do when it starts getting to you?

Advice on Treatment

ElectroConvulsiveTherapy (ECT)
Simple, Temporary Remedies

Hedonic Intervals

The Win-Win Attitude
The Morning Depression
The Place of everyday worries in Depression: 

For interesting fictional examples

What is it?  Here, by "depression", I write about what the classifiers in 2021 call "Major Depressive Disorder" (MDD), meaning a severe depression of more than 2 weeks that is not or has not in the past been accompanied by a manic, psychotic (See, also, Chapter 27) episode.

 Aspects of Depression:  At Depression's core is lack of energy and lack of ambition that goes beyond the usual mood shift. One does not want to do anything new, one gives up on future, loses joys of life: eating, reading, sex, entertainment. In short, one does not want to do anything and is good for nothing. The cognitive triad -- helpless (The depressed One), heartless (His community), hopeless (His future) --  of psychologist Aaron Beck (Cf. CBT, cognitive behavioral therapy.) is useful to understanding how the patient views his depression. The patient, over-anticipates the worst things that might happen to him (Ergo, Dreams of Castles in air!) and lives in the shadow of a very bad future.  Often he continually blames himself, forgetting the good things he accomplished. And this is brought on by bad events in his life (exogenous depression) but for some personalities it seems to grow out of their psyche (endogenous depression).

That is a vast generalization but reasonably accurate.  Depression ought to be a condition of mind and body that starts for a reason and does not go away in just a week or two.  Practically there are two main causes of depression, which we may call types: depression brought on by external events in one`s life, like the loss of a job or other types of personal failure, or depression that does not seem to have an external cause, but rather creeps up on one.  In either case the symptoms, described above are the same but in the latter the depression is often more severe.

  Warning: today there is a great confusion among psychiatrists and psychologists on whether or not depression may be a continuum of normality but not an illness. Therefore I would not necessarily trust psychological or psychiatric approaches to depression that you might read in tomes or hear in lectures.  What counts is how it is affecting you, what you believe might be its cause, and how to rid yourself of the terrible symptoms I have just described.

Another aspect of Depression is variance in time. Every day, everyone has moments of feeling depressed. Sometimes there are days we are depressed – blah days – and other days we fly high. Here we see the normal cycle of emotional energy. In certain types of personalities, this cycling dominates the clinical picture and then we have the Bipolar, which is a separate diagnosis and a whole `nother kettle of fish.

Still another aspect of Depression is its variation among normal individuals: we all know the bright-eyed, life-of-party extrovert and optimist; and also the no-energy type, Gloomy Gus, always imagining a worst case. Most of us are in-between. We don't know why persons differ but we know it is not necessarily a disease.

Yet another is change with aging. Using each individual as his or her own control, it seems as one ages one feels Depression more frequently and deeply. But it does not necessarily mean one has a disease called Depression: it can also be shrugged off as normal aging.
(Today in 2021, "Depression" is not used by academic psychiatrists; today it is a "Mood Disorder" divided into Unipolar or Bipolar by the absence or presence of cycles. The latter is Bipolar Depression Disorder (BPD) which is a different disease dealt with in the previous chapter.

And depressive feeling can be removed by eating, by a drink, a smoke, a coffee, a tea, a pill, a shot. Here, a chemical effect seems obvious.

So in dealing with Depression we should consider it in terms of personality type, time, aging and chemical influence.

Labels of Depression - Its History: What in 2021 is Depression can be a loss of lust for life, or a down-mood of the moment, or a feeling of failure, or a response to catastrophe or a symptom of sickness or a disease diagnosis. At worst it ends in suicide. Until 50 years ago, Depression as a mental disease was considered a complication of psychosis or a symptom of a neurotic state or a part of a physical illness or a feeling of failure in life. When Depression arose in a non-mentally ill person, he or she was thought to be reacting to stress in the environment, and the treatment was to remove, modify or de-emotionalize it. 

Now we are in the era of anti-depression pills and it has put Depression into public spotlight as chemical deficiency. Those who previously would have been told they felt bad because of attitude, stress, or illness now began to be told they had a deficiency disease. Criteria were assembled to define this entity, and before anyone knew it we had a worldwide epidemic and 10% suffering from it.

This may sound like success story but it ain't. If it really had been – like the cures for TB, syphilis, cervix cancer – with the advent of the anti depression pills, the incidence of Depression and the death rate from its suicides should have dropped off the curve. Not only hasn't that happened but the reverse has. Explainers-away say it is due to change in diagnostic criteria or other complicating factor but are not convincing. Fact is, there has been no solution to Depression; rather an attitude change tells one who goes through stress that makes him feel depressed that he has chemical deficiency requiring pills. A new disease with drug dependence has been created.

  A Practical Explanation of Depression and Causes is to look at each depressive episode as caused by environmental stress that, by causing great frustration, extreme grief or physical illness has inhibited the production of anti depression neurotransmitters like norepinephrine or serotonin or dopamine and lowered the threshold for the person to feel depressed and act out. This allows us to treat depression at various levels with all available therapy: At the psychoanalytic level by discovering what started the chain of events and how one's individual past equips one to cope with it; at supportive-psychotherapy (Aaron Beck`s cognitive model emphasizing the psychological significance of a person’s belief about himself, his personal world, and future—the SWF cognitive triad; for details read “Cognative Therapy” in Kaplan&Sadock’s Synopsis of Psychiatry, 11th Ed, page 872.) level by fostering attitude-change so a patient can better tolerate and not act out his feeling; and at drug and other treatment level using the pills or other chemical or electrical treatment as assist to prevent severe suicidal depressive periods. This explanation fits the concept of Depression as excess of normal defense reaction that protects one during great frustration – loss of loved one, inability to succeed because of imbalanced odds – when, if one were to proceed in one's normal energetic way, one would get one's self into trouble. One should respect such a defense, when one begins to experience a depressive episode, and try to read its message. It might be something like ‘Don't make positive decision because you'll be getting in over your head’. Sometimes, after considering a cause of depressed feeling one may choose to disagree with its message but one should be aware of it. This defense becomes disease when it gets to be so much it interferes with social life and enjoyment.

At core of depression is frustration. We want an important object and it is denied us due to death, separation, or having one's love ignored; or because of lack of promotion or lack of success; or even imagined loss of life. (Belief that one has or will get deadly illness.) Preventive here, in planning out one's life (or parents planning a child's life), is to try and avoid obvious sources of major frustration. (Someone trying for vocation they are unsuited for.) Another is to diversify activity and enjoyment. Do not put all emotional eggs in one basket: loving only one person, concentrating on only one job, project or plan. Advance in many areas on broad front. And keep in mind, your sudden depression may be coming from medication: e.g., reserpine used for hypertension or L-dopa used in Parkinsonism, or many of the tranquilizers overdosed.

Antidepression Medication: The main anti depression medications in order of recency and popularity are the serotonin/norepinephrine reuptake inhibitors (SNRI's increase serotonin and norepinephrine in the brain) such as Venlafaxine aka Effexor, Duolexetine aka Cymbalta, et al); the selective serotonin reuptake inhibitors as Prozac, Zoloft, Paxil, Celexa, Lexapro); the tricyclics such as the generic imipramine aka Tofranil, amitryptiline, desipramine, doxepin, clomipramine, trimipramine); and the monoamine oxidase inhibitors (MAOIs; phenelzine, isocarboxazid, tranylylcypramine) - all of these up the amine-neurotransmitters at the nerve junctions in the part of the brain that produces feeling tone (feel good, feel bad). The clinical effect of these drugs was discovered starting in 1950 and when, later, in the 1970s, their chemical action at the nerve junctions became clear, a biochemical theory of depression as due to a deficiency of amine (-NH2) neurotransmitters arose and dominated the treatment of depression. Today, the theory is considered too simplistic and it is realized that clinical depression is, first of all, a mix of a DNA-based trait, an environmental mishap or an underlying medical illness or wrong use of medication. And the idea of these medications "successfully treating depression" is vague.

The best recent study has shown that about 50% to 70% of treated patients have a successful treatment in that the drug relieves their depressive state.  This study, involving thousands of treatments with control loops showed the top four anti-depressives (Major depressive disorder, no mania) were Escalitopram, Mirtazapine, Sertraline and Venlafaxine but, when tolarability and efficacy were combined as top desires in a medication, then Escitalopram and Sertraline (aka Zoloft) were the top two.

 Initially and until about 20 years ago the tricyclic drugs led by Imipramine (Tofranil) were most popular, Then the SSRIs appeared led by fluoxetine (Prozac) and got hyped and today the SNRIs dominate.

Patients are instructed not to expect good results until 2 to 6 weeks on the drugs.

What to do when it starts getting to you? Because depression may be normal feeling, it's hard to draw a line and say, “Now I ought to start treatment.” Each of us has different tolerance level. Today, depression is a vogue diagnosis (also at times, a vague one : Doctor, family member, acquaintance or affected person himself puts on the label given slight excuse. In my case, although not being typically depressed I find at age 88 and in my present condition I have a boredom that includes depression which may be relieved by taking the Tofranil or using an opioid like codeine or pentacozine (See my chapter on Opium drugs) and also I sleep easier so that the boring parts of a 24-hour day pass more easily.

The following is my advice on treatment for clinical depression. First, when you become depressed, pay attention to your feelings and try to vary your behavior. (E.g., If you’re a brunette, take note of the 1950's hair bleach advertising slogan, “Is it true blondes have more fun?" and try varying your look.)

Then, go somewhere far from the madding crowd (cf. Thomas Hardy) and do self psychoanalysis (See Chapter 33 in Notebooks 9; also, a friendly authority figure may assist) to see if you can locate what frustration is at base of your Depression. If it is something you think there's a reasonable chance of overcoming (e.g., your spouse's infatuation with another person), move ahead with an “I shall overcome” program. If it is something impossible to overcome (recent death of a parent) start behavioral psychotherapy to desensitize to grief. If it is a frustration you cannot avoid in your life (A husband who beats you), separate from it.

I write here about usual Depression, not part of manic depression or schizophrenia or involving suicide tries.

ElectroConvulsiveTherapy is the applying of electrodes on the scalp, giving muscle relaxant anesthesia, and shocking a patient's brain under controlled conditions. It is effective for ending a period of severe depression especially with mania but controversial from the memory losses it may incur.  I am not against it in bad case where nothing has worked and psychosurgery might be considered. Recently half-cranial electroshock has been claimed to give less memory loss but also blamed as being less effective. A more recent treatment is magnetic stimulation through the scalp. It seems harmless and, if not terribly expensive, no harm to try it as long as supervised by psychiatrist.

Simple, Temporary Remedy - the affect of body heat: Warming the body either by a hot bath or shower or lying in warm sun, as I sometimes do on my Japanese futon in a southern window open exposure at noontime will quickly and temporarily replace a depressed feeling with a feeling of contentment and a lack of anxiety. Of course, it is not always applicable and does not get at the core causes but can be useful in particularly bad moments or when bad depressions can end in suicide.

Hedonic Intervals or Moments: Anhedonia (the lack of life enjoyment) is frequent in depressives. The person does not have the usual joys of life. My lifetime observation which I have made into this anti-depression advice is to cultivate what I call hedonic intervals or moments. These are periods of not unhealthy enjoyment. Example from my life is to take a break for a delicious, not unhealthy snack while enjoying a good read, a DVD or free internet movie or musical interlude.

Here is a best description of a hedonic interval and its affect on one's mental state:  "One day in winter, on my return home, my mother, seeing that I was cold, offered me some tea, a thing I do not ordinarily take. I declined at first, and then, for no particular reason, changed my mind. She sent for one of these squat, plump little cakes called "petites madeleines," which look as though they had been molded in the fluted valve of a scallop shell. And soon, mechanically, dispirited after a dreary day with the prospect of a dreary morrow, I raised to my lips a spoonful of the tea in which I had soaked a morsel of the cake. No sooner had the warm liquid mixed with the crumbs touched my palate than a shudder ran through me and I stopped, intent upon the extraordinary thing that was happening to me. An exquisite pleasure had invaded my senses, something isolated, detached, with no suggestion of its origin. And at once the vicissitudes of life had become indifferent to me, its disasters innocuous, its brevity illusory—this new sensation having had on me the effect which love has of filling me with a precious essence; or rather this essence was not in me, it was me."
(Quoting physician-author`s comment: sounds like relief from hypoglycmia.)

I look forward to the Hedonic break. It gives me a reason during each day to feel good and to want a future day. This is not advice just to treat depression; it is a general life advice that acts as preventive or an ameliorative of Depression. Most depressions are coming from bad event or influence at a point in one's life but the depressive effect can be weathered better when you can look forward to the hedonic intervals each day. Of course, we all have different schedules and each person arranges the intervals in accordance with his daily work schedule. And the above perhaps overemphasizes simple hedonism such as eating good food or having other brief enjoyments but also I do not want the reader to forget the more basic enjoyments of one's life such as succeeding at your work, marrying happily and having kids and so forth which are also contemplative goals that keep one wanting to live to enjoy life despite the obvious fact of transiency.

The Place of everyday worries in Depression:  I call these worries "small paranoias" because they are free-floating mental sources of anxieties we all have: like fear of illness and premature dying, like the worries the IRS will audit and other money worries like specific things we have done in our lives that we regret and might end up being punished for.  As much as possible a mind free of these small paranoias will be a mind resistant to clinical depression.  So get to work and take care of these worries by solving the problems or discovering that they are not real.

The Win-Win Attitude: Depressive episodes start from things not happening as you planned. I developed a Win-Win approach. For example, an acquaintance had been planning to visit with me in Japan but we had a falling out and she ignored me. Though I had been looking forward to seeing her, I found myself happy also with her change of mind because, it occurred to me that her not coming would save me money and time. So I ended up happy. With Win-Win you are happy either way something turns out. But you need to have a mind free of hang-up paranoias to work out interesting possibilities. Even a loved one's death, a cause of grief and depression, can give happiness by considering the freedom it gives you. I struggled through my late wife's 16-month bout with cancer. And the moment after she died, I felt a happiness because I realized her death had freed up my time and the possibilities for other joys.

The morning depression that stops you from starting your daily chores is something I experience and guess that some of you readers do too. It may be pleasant, especially on a cold, rainy morning to want to fall back on the pillow and drift of into a pleasant fugue state sleep. More often it is misery with you recounting all your mistakes. When it happens to you, do a quick psychoanalysis to see if it is a rational response to starting your day. If it is just avoidance of less than pleasant but very necessary, should-not-be put-off chore or duty, fight it and break it and get up. If a quick coffee available, drink it. 

For interesting fictional examples of the psychoanalytic treatments of Depression, click
12.36 Helping Dan Die - The Morphine Effect, 12.(60-61) Self PsyA/Hitler's 55th Birthday/Eddie ... , 13.27 Psychoanalysis, 13.28 Psychoanalysis of Richard S and 14.(9-10) Stan's Ideal Psychoanalysis & Psychothe...

 END OF CHAPTER. To read next click 9.29 Schizophrenia's Startling Story