Shooing the Blues Away: How Should Depression Be Managed?

Doc Gumshoe looks at depression

By Michael Jorrin, "Doc Gumshoe", January 27, 2016

[ed note: Michael Jorrin, who I like to call Doc Gumshoe, is a longtime medical writer (not a doctor) who shares his non-investment thoughts with us a couple times a month. I suppose it’s a coincidence that he’s looking at depression at a time when we’re all a bit depressed about the market, but maybe it’s a good time for us all to learn more about this disorder. Michael’s past columns are here if you’d like to see more.]

W. C. Fields famously pronounced the following cure for insomnia: “Try to get a lot of sleep.” Following his eminent lead, we could say that the recipe for curing depression should be “Cheer up!” Oh, sure, easy to say.

And yet, that’s precisely the goal of treatment. The question is, and always has been, how to attain that goal, or even come close to it.

I want to start out by asserting that the mere fact that we now commonly discuss ways of treating depression is a sign of genuine progress. Within the memory of many of us, admitting to being depressed and seeking some kind of treatment for depression was seen as a sign of weakness of character. People were supposed to accept adversity. As Longfellow put it,

“Be still, sad heart! and cease repining; 

Behind the clouds is the sun still shining;

Thy fate is the common fate of all,

Into each life some rain must fall,

Some days must be dark and dreary.”

Depression, as a condition affecting a considerable number of our fellow humans, has been recognized since the days of the ancients. It was known as “melancholia,” based on the Greel words for black (μέλας, melas) and bile (χολή, khole), and was thought to be caused by black bile, one of the four humors that essentially ruled our lives. (The other three humors were blood, which made us sanguine or hopeful, phlegm, which made us phlegmatic or slow and thoughtful, and yellow bile, which made us bilious or disagreeable.) Robert Burton, in his Anatomy of Melancholy, an eloquent and poetic 17th century work, suggested good food, music, enough sleep, meaningful work, and talk with friends. Not too bad a regimen to induce cheering up.

Right down to the middle of the 20th century, and persisting even into the present, there has been a tendency to try to distinguish real genuine bona fide depression from unhappiness over external events. The German psychiatrist Kurt Schneider distinguished between what he termed “endogenous depression,” meaning that it arose from an internal mental state, from “reactive depression.” The fourth edition of the Diagnostic and Statistical Manual of Mental Disorders, the DSM-IV, for example, excluded bereavement in its definition of major depressive disorder – if a person had lost a relative or a close friend in the immediately preceding period, then no matter how else that person felt, he or she was not to be diagnosed as being depressed. The death of a person that one loves should presumably be considered in the same category as the rain that must fall into each life. You were supposed to get over it.

The new edition, DSM-5, excludes that exclusion. Some people have a hard time getting over such events, and other “real world” events and situations as well; something is going on inside them that exacerbates or prolongs the feelings. The distinction between what happens in the outside world and what’s going on in our brains is not so clear. Reactions to real world events can result in endogenous depression; neurotransmitters do their thing more or less regardless of the cause.

Looking at depression from the outside

Let’s defer thinking about depression from the perspective of the individual affected by this condition, and take a look at the impact of depression on our society. In a word, it is enormous. Before throwing a few quick facts at you, let me first specify that these data are based on a condition defined as “major depressive disorder,” according to the criteria in the previous edition of the DSM, except that unlike those criteria, no exclusions were made for medical illness, bereavement, or substance abuse disorders. A major depressive episode is defined in DSM-IV as a period of two weeks or longer during which there is either depressed mood or loss of interest or pleasure, and at least four other symptoms that reflect a change in functioning, such as problems with sleep, eating, energy, concentration, or self-image.

You may be thinking that the DSM-IV definition is rather broad – after all, at some point nearly everyone has a problem with one of those categories. But on closer examination, how often do we have problems with four of those all at the same time, coupled with a loss of pleasure? That’s when the little routine problems that plague us every day morph together and become a pathologic condition.

So here are those few quick facts, from the National Institute of Mental Health:

For 2014, the latest year for which we have data, 6.6%, or about 16 million adults in the US had at least one episode of a major depressive disorder (MDD). MDD affected nearly twice as many women, 8.2%, as men, 4.8%. The 18 to 25 year-old cohort has the highest prevalence, 9.3%, and this drops to 7.2% for 26 to 49 year-olds and to 5.2% for people over 50 years old. Whites have a slightly higher prevalence (7.1%) than blacks (5.4%) and Hispanics (5.2%). And Asians have the lowest prevalence, 4.2%.

Rates of MDD are higher in persons whose sexual orientation is other than heterosexual, and the lifetime prevalence is nearly double in lesbian, gay, and bisexual persons, 71.4% versus 38.2% in heterosexuals.

The estimated total annual cost of depression in the US is upward of $80 billion. Unlike the costs associated with other illnesses, which are largely related to the cost of treatment, about 70% of the costs of depression are not treatment costs, but related to lost productivity. According to a study by the Epidemiologic Catchment Area, persons with an episode of MDD were 27 times more likely to miss work than those without this disorder, and when they were at work, they were much less likely to be productive, a phenomenon termed “presenteeism,” meaning, more or less, that the person with MDD is physically present, but not able to function normally.

Most of those lost productivity costs are borne by employers, without, of course, any reimbursement and not much recourse. A big chunk of the costs are, however, absorbed by the health-care system. Persons with major depressive episodes are about seven times more likely to present to hospital emergency departments than those without MDD, and many of those ED visits are not covered by health insurance.

If everyone with an episode of MDD sought medical intervention, the costs would be far higher. However, based on estimates by the National Suicide Prevention Lifeline, fully 50% of persons who experience major depression do not seek treatment of any kind.

Before we go on to the real meat of this piece, which is how do we treat or manage depression, no matter how it is defined, I need to inject a dose of Doc Gumshoe skepticism regarding some of those statistics.

It should be evident that the great majority of diagnoses of depression are based on the patient’s self-report, and that, regardless of the effort that has been made to create accurate questionnaires for the assessment of depression, individual patients will answer those questions according to their own disposition and experience. Are women really twice as likely to experience major depression as men? Or is it possible that men are about half as likely to acknowledge the feelings of depression as women? Or do men have more op