DEPRESSION

Also known as: "Feeling Down", "The Blues", Depressive Illness


Steve, age 38, arrived at my office tearful and distraught over the recent break-up of his five-year relationship with his lover. Only at the insistence of his friends and a co-worker did he finally decide to seek professional help.

Steve appeared beaten down and dejected and reported feelings of misery and profound sadness. He stated, "I've never felt worse in my life." Steve also reported that he was not eating, had lost several pounds, often awoke at night with recurrent nightmares, had difficulty concentrating at work and had little interest in participating in social activities or going to the gym.

During our initial session, Steve said that he felt lonely and had few people he could turn to for help and support. Steve was closeted at work and had told only one of his co-workers that he was gay. Although his family knew about his sexual identity they remained uncomfortable and showed little support for Steve's relationship.

I asked Steve if he had ever thought about hurting himself and he responded, "If I died, it would probably be a relief." Steve is clearly suffering from a major depression episode.

Intro
Depression (or Depressive Illness) is one of the most common disorders seen by therapists and psychiatrists in outpatient care. For most people depression is a passing mood. However, for others, it is a debilitating chronic illness with severe consequences.

According to the National Institute of Mental Health, 9.5 percent of the U.S. population, or about 19 million American adults, suffer from depression. An episode of major depression can last several weeks to several years. The devastating effects on one's work and personal life has been explored and documented extensively over the past several years. Depression interferes with a person's ability to function normally and enjoy a healthy and satisfying life and affects friends and family members as well. Depression is, by far, the number one cause of suicide.

Depressive illness is not a "gay disease". However, the prevalence of depression amongst gays and lesbians is higher than in the general public due to the social, political and religious discrimination and a lack of family and institutional support.

What is it?
Depressive Illness falls under the category of Mood Disorders, which is further divided into two subcategories called Depressive Disorders (Major Depression and Dysthymia) and Bipolar Disorders (Bipolar Disorder and Cyclothymia).

When lay people speak of "depression" they usually mean feeling down-in-the-dumps, sad or unhappy, something we all feel from time to time. These types of symptoms are referred to as Dysthymia, a milder but chronic form of depressive illness involving long-term, chronic symptoms that do not necessarily disable you but keeps you from functioning well and feeling a sense of satisfaction with your life.

When mental health professionals speak of depression they are usually referring to the symptoms of Major Depression, a mental disorder involving persistent feelings of worthlessness and hopelessness, thoughts of death and suicide, and an inability to feel pleasure or take interest in life.

Another type of depressive illness is Bipolar Disorder, formerly known as manic-depressive illness. Bipolar disorder is characterized by cycling mood changes from severe highs (mania) to lows (depression). These mood changes can be dramatic and rapid or slow and gradual. A milder form of bipolar disorder is referred to as Cyclothymia.

Symptoms
Regardless of its cause, depressive illness presents as a cluster of common signs (observable indications of depression such as social withdrawal or depressed appearance) and symptoms (reported indications of depression such as depressed feelings or suicidal thoughts) and reaches a final set of emotional, biological and cognitive dysfunction.

Depression

  • depressed mood
  • significant weight loss or gain
  • insomnia or hypersomnia
  • fatigue or loss of energy
  • excessive or inappropriate guilt
  • recurrent thoughts of death
  • social withdrawal
  • lack of interest or pleasure
  • decrease or increase in appetite
  • feeling restless or slowed down
  • feelings of worthlessness
  • difficulty thinking or concentrating
  • suicidal ideation or suicide attempt
  • unresolved grief

Mania

  • uncontrollable elation
  • reckless hyperactivity
  • exaggerated self-assurance
  • paranoia
  • poor judgement
  • sleeplessness
  • intrusive gregariousness
  • unusual irritability
  • grandiose delusions
  • racing thoughts

How is it acquired?
There is no single cause for depression. Several biological and/or psychosocial factors may contribute to depressive illness. Genetic vulnerability and biochemical imbalances are biological causes of depression. Psychosocial causes include drug and alcohol use, early or recent significant loss, lack of positive reinforcement and support, prior history of physical or sexual abuse and poor self-esteem.

Gays and lesbians are no different than heterosexuals in terms of biological causes of depression. However, due to our discrimination and rejection, we often grow up feeling different, isolated, or "ill", and receive very little positive reinforcement and support. Often, we turn to drugs and alcohol in an effort to "numb" our emotional pain. This ongoing discrimination coupled with a lack of support adds significant stress to our lives and eats away at our sense of self-worth and self-esteem. We become overly susceptible to feelings of depression. Homosexuality, itself, is not a cause for depression, but rather, it is the rejection and discrimination gays and lesbians experience (sometimes daily) that often leads to these feelings of profound hurt and depression.

How to treat it?
While there is no definitive cure for depressive illness, professional treatment can reduce symptoms, shorten the length of episodes, and prevent relapse. The most common goals of treatment are:

  • assess and prevent danger to oneself or others
  • provide a safe environment
  • assess the need for medication
  • improve problem solving and coping skills
  • correct irrational and negative thoughts
  • resolve issues of loss
  • improve self-esteem
  • improve eating and sleeping patterns

     

  • educate and encourage involvement of support persons

Management and treatment of Depressive Illness is carried out through one or more of the following interventions:

  1. Crisis/Suicide Prevention
  2. Medication
  3. Psychotherapy
  4. Family Involvement

Myths dispelled
Here are some facts to clear up some common misconceptions.

"Why don't you just get over it?"

Of course depressive illness is not something people can simply "get over". Depressed people need care and support from the important people in their lives and may also need professional help.

Prevention
There is no recipe for depression prevention. Biological causes may lead to a higher susceptibility to depressive illness for some, while troublesome psychosocial issues surround nearly everyone, especially gays and lesbians. Life is difficult and full of conflicts, obstacles and losses leading to stress, frustration, and hurt feelings. The hallmark of a happy, healthy and satisfying life is not one void of conflict and loss, but rather, one where you can successfully manage such issues when they arise. How we live our lives and the choices we make have a great deal to do with the quality and satisfaction we feel. In this regard, here are a few suggestions that may help you in dealing with whatever curves life throws your way.

  • Try to accept that loss is part of life
  • Don’t be afraid to reach out and accept help and support from others
  • Accept that we can’t control everything around us
  • Make better, more informed choices that create less turmoil for you
  • Try to avoid those "trigger issues" that lead to anger and frustration
  • Stop being so critical of yourself, and of others
  • Create more realistic expectations, and you will be less disappointed
  • Realize that nothing is truly all your fault
  • Acknowledge the good in you
  • Stop beating yourself up
  • If you’re good at caring for others, add yourself to that mix
  • Take good care of yourself, you deserve it

Of particular concern to Women
Two-thirds of all depressed patients are women. The sex difference ratios are similar in many parts of the world, regardless of levels of income and education. There are many factors that probably contribute to this difference including menstruation, pregnancy, miscarriage, hormone fluctuations that occur during menopause, postpartum period and premenstrual syndrome (PMS). However, research has not shown convincing evidence that the explanation is genetic or involves some feature of the female reproductive cycle.

Some studies suggest that women have been "schooled" in helplessness and passivity and made dependent on others for self-esteem. Women are also said to be more sensitive to personal relationships and therefore more vulnerable to loss. Studies have also shown that in unhappy marriages the wife is three times more likely to be depressed than her husband.

Of particular concern to Men
There may be several explanations for why men are statistically less prone to depression. For example, men are less likely to admit or even acknowledge their feelings, and fail to recognize depression. Men often disguise their depression (even from themselves) in many ways: with alcohol, involvement in new activities, diving into work, or other unhealthy obsessions which distract them from their feelings. Finally, men are less likely to see doctors and mental health professionals when they are unhappy; this could lead to a significant underreporting of male depression.

Special notes
Mental health professionals consider several possible diagnoses when a client presents with the symptoms of depressive illness. These include:

  • Adjustment Disorder with Depressed Mood
  • Bipolar Disorder
  • Dysthymic Disorder
  • Cyclothymic Disorder
  • Major Depressive Disorder
  • Personality Disorder
  • Bereavement

Several related issues would also be considered. These include:

  • Drug or Alcohol Use and Abuse
  • Significant life changes
  • Recent loss
  • Anniversary of a significant loss
  • Difficulties in a relationship
  • Change in health status
  • Work related stress
  • Financial difficulties

Prevalence
Depressive illness is one of the most widespread mental health disorders. According to the National Institute of Mental health, about 20 percent of the U.S. population report at least one depressive symptom in a given month, and 12 percent report two or more in a year.

According to the Harvard Mental Health Letter (December 1997), "untreated, the average episode of depression lasts six months. In most cases the symptoms return periodically, for an average of five to seven episodes in a lifetime."

There are no definitive statistics on gay and lesbian depression. Because many gay and lesbian people choose not to divulge their sexual identity to healthcare workers, the prevalence of depression amongst gays and lesbians may be significantly underreported. Additionally, many medical and healthcare professionals fail to consider the effects of stigmatization and discrimination as causes of their patients depression. It is easy to image that discrimination coupled with limited support for gays and lesbians could explain the higher prevalence of depressive illness within the gay and lesbian community.

Complications
Dangerous Complications

Crisis/Suicide Prevention – If you or someone you know suffers from depression, the possibility of suicide must be considered. Suicide is the eighth leading cause of death in the U.S. and approximately 90 percent of suicide victims suffer from a mental or emotional disorder. Whenever someone appears to be significantly depressed the following questions should be considered:

  • Do you sometimes feel that life isn’t worth living?
  • Do you think about death often?
  • Do you sometimes think that if you died, no one would care?
  • Have you had thoughts of killing yourself?
  • Do you know how you might do it?
  • Have you actually made a plan?

If you answered "yes" to any of these questions, seek professional help. If you answer yes to any of the last three questions, your risk of suicide is dangerously high; please turn off your computer and get immediate professional help.

Only qualified medical and mental health professionals can determine the level of suicidal risk for a severely depressed person.

Medication - The most common treatment for depressive illness is antidepressant and antimanic medication prescribed by a psychiatrist. These drugs usually begin to work within a few weeks, though your sleep and appetite may improve much sooner. Side effects include a dry mouth, blurred vision, weight gain or loss, constipation, difficulty in urinating, high blood pressure, nausea, agitation, drowsiness, and impotence. Report all side effects to your doctor, who will monitor and adjust doses. Often different types of medication are tried in order to find the one best suited for you. Not everyone responds well to medication and some people can not tolerate their side effects.

SSRIs (selective seratonin re-uptake inhibitors) are one of the most common class of antidepressant medications doctors prescribe and include Prozac, Zoloft, Paxil and Celexa. Impotence is a troubling side effect of SSRI antidepressants and may not be dose related. Impotence in men, of course, means a failure to achieve of maintain an erection. Doctors are now realizing that SSRI antidepressants can affect women by reducing their sex drive. If you develop impotense after starting an antidepressant, talk to your doctor. You will probably need your medication changed to a different class of antidepressants.

Antidepressant medications are powerful drugs and should be prescribed by a psychiatrist. All too often people obtain prescriptions for these drugs from their primary physicians for a little "pick me up" when they may not need medication at all.

Psychotherapy - Drug therapy is usually not enough. While drugs help shorten your depressive episode and reduce symptoms, they do not help you to better understand the cause or learn to better cope with the illness. Therapy provides you with common sense advice, helps you identify and avoid situations likely to spark another episode, educates you about the "facts" of your illness, and helps you view yourself and your life more rationally, positively and constructively. Your therapist helps you confront problems and offers reassurance, encouragement and support throughout treatment. Through therapy you learn coping skills: how to better manage feelings, how to effectively deal with anger and frustration, repair family ties, work through career difficulties, and develop healthier and happier relationships with family, friends and loved ones.

Family Involvement - The importance of family involvement cannot be overemphasized. A major depressive illness can damage relationships and destroy families. Even the most supportive and resilient of loved ones can become drained, worn out, hurt and disgruntled. The most important reasons to include family members in therapy is to support the patient, support the family and to treat family related issues that contribute to the depressive illness.


by Shaun Bourget, M.A.,M.F.T.



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