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A new name for depression might be "hypothalamo-pituitary-adrenal-axis dysfunction", suggests NIMH neuroscientist Philip Gold. "People confuse (the word depression) with the everyday sensation of feeling despondent and dismiss it." We run into problems when we think that we can control full-blown, set-in depression. However, writes Whybrow, depression is a disability of the mind when it is affected by a disordered mood. We blame it on loss of willpower, or a lack of self-discipline when actually, "our coherent image of the world is a unique interactive process between the brain's biology and what we experience. Each can change the other." To truly face depression as an illness of the mind, he says, we need to accept that it has biological underpinnings. It can be triggered by stressful events, but only in someone who has, what Whybrow calls, a "neurobiological Achilles heel." The Shattering of the Self Depression is a prolonged sense of grief. And grief, Whybrow believes, is a "shattering" of oneself. It is difficult to recognize oneself in depression because of one's distorted self-reflection. All of the housekeeping elements such as cognitive thought, memory, concentration, and decision-making, are disturbed when one is depressed. Our limbic system, or emotional center of our brain, is still as ancient as it was in the saber tooth tiger days. We deal with stressful situations as we did then „ with our fight-or-flight response. However, Whybrow says, our actual presence of danger has changed. Danger was once uncertainty about the animals in the dark forest surrounding our camp; now about the dark forest in our mind. Our fears are more deeply psychological, hidden, bearing no physical form. Depression, he believes, originates from our inability to cope effectively with this uncertainty and our broken connections from one another. When one feels a part of the tribe, one is safe and can deal with the uncertainty of the surrounding forest. "We don't have the same basic fears as other people in war-torn areas," says OSU Professor Cydreese Aebi, R.Ph, Ph.D, "and yet the stressors can be equally as strong. They are different stressors for us. The complexity of our lives, the complexity of our society „ while people in Israel worry about being shot by stray bullets, the stress can cause the same reaction in our body when we worry about something else." "Since depression is a mental illness you end up with a lot of shame around it," says Alice Duffy, Licensed Clinical Social Worker (LCSW) in Eugene, "There's a lot of stigma, a lot of hiding behavior so it's almost better to have mom be a drunk than mom be depressed." We do not admit readily to an illness or disability of the mind, however, we will yield more easily to the fragility of our aging bodies. "We cling," Whybrow says, "to invincibility in spirit." No Class Boundaries Depression cuts across class lines, says Dr. Gary LeClair, obstetrician/gynecologist (ob/gyn) at All Women's Health Care in Eugene. "Depression is not how good it is, depression is intrinsic. It doesn't matter how good things are, you are still depressed." The upper middle class is usually the last group of people to be diagnosed with depression, and yet, Aebi says, "Some say that depression hits the higher income bracket even more (than other social classes) .... nobody is really immune to it." "I have been in practice for 30 years," says LeClair,"and I definitely see more depression. I think it's the pace of our society. I think things move past our face so quickly. You have Iinternet, e-mail, now everybody's got cell phones. It used to be if you weren't home, nobody would talk to you ... There is a real loss in the stability here, in America."
Dr. Cristin Babcock, ob/gyn at All Women's Health Care in Eugene, agrees. "In 1970," she says, "one income bought the average American house. By 1990, it took two average incomes to buy one average American house „ so to have those things we consider normal, both parents have to work which means there's going to be increased stress in people's lives." Depression can be an intrinsically genetic predisposition, it might be a result of environmental life stress, or it can be a result of inertia; knowing something in one's life is not working, and not taking the initiative to make positive changes, says Duffy. It can also mask other medical, metabloic or social problems such as eyesight problems, hormonal changes, domestic violence, substance abuse, etc. When Alexander Solomon went through a serious bout of depression he was told it could be cured by medication, he writes in his New Yorker article "Anatomy of Melancholy." However, this is not true, he says. "Depression these days is treatable; you take antidepressants the way you take chemotherapy for cancer." When patients are first diagnosed by their primary care physician with depression they are in one of their most vulnerable moments. Herein lies the new role of physicians prescribing psychiatric medication. While physicians do not have the time, nor the training to counsel their patients, they hold what could be a very powerful responsibility in helping their patients find the type of help they need. If the physician or nurse can help a patient, says Aebi, "just with that first appointment, it would be very beneficial for that patient." The Therapy Gap Studies show that drug therapy coupled with psychotherapy is considered optimal treatment for depression. However, there is a gap between the physician's and therapist's office. The new antidepressants work so well at enabling patients to safely cope with their lives with a minimal amount of side effects that many patients use them and go on living their stressful lives. The most disturbing trend is that people will try medication first rather seek out therapeutic help, says Dr. William Balsom, family practice physician in Eugene. Patients do not seek help for a myriad of reasons, he says. "They have time and money constraints, they are embarrassed, or they have limited or no access because of their health insurance benefits," he says. Insurance access has made it difficult for the patient to receive counseling, says LeClair. Patients are often confused as to how they obtain counseling. Many believe they must go through their physician when that is usually not the case. Quite often, he went on, even if they have the preferred provider list from their insurance company, the patient does not know who to call. "I don't think we can use pharmacotherapy as a crutch," Aebi believes," I think we need to really delve in and see what the cause is „ if we can find the cause. ... That's where the physician, and the psychiatrist or the counselor really work together. Drug therapy is just one part of it," she says. Typically the mental health and medical community reside parallel to one another. There is very little crossover due to the confidentiality of patient information in therapy, and the time constraint under which physicians operate. However, this is an important aspect of health care that needs to be addressed, says Dr. Rupert Goetz, medical director of the Office of Mental Health Services for the state of Oregon. "There is no solution to depression", he says, "but any communication across the primary care/mental health interface between elements of programs, the providers, and the patients are critical pieces of the puzzle." In her four years of private practice in Eugene, Duffy finds that when she can establish contact with physicians, her clients get the most advantageous care. "I've had more than one physician that I have had to call and say, excuse me but your patient is suicidal," she says. "They may not be scheduled to see that patient for another 15 days. Patients are afraid of disturbing the doctor and by the time someone gets suicidal, they don't necessarily want a lot of help." "Given a clear and and plausable alternative to suicide, I find that depressed people rarely want to die," says Dr. David Shaw, a Seattle psychiatrist who specializes in mood disorders. "People are just looking for some relief from the incredible sort of distress clinical depression causes." The New Meds Prior to the late 1980's, tricyclics were the only medications available to treat depression. They are so named because of their three-ring chemical structure. Tricyclics came with many severe side effects, including the danger of overdose, says Aebi. It was hard to treat depression with tricyclics, she went on, because patient compliance was poor. "There were a lot more office visits, a lot more emergency room visits ... we had a lot of deaths due to tricyclic antidepressant overdose," she says. The new antidepressants or selective serotonin reuptake inhibitors (SSRI's) such as Prozac, came on the market in the late 1980s. Serotonin is one of three neurotransmitters that balances the chemistry of mood, the other two being norepinephrine and dopamine. SSRI's and many other mood altering drugs, achieve their effect by mimicking neurotransmitters' activity, thus changing the chemical balance in the brain. The difference between tricyclics and the newer antidepressants is that while tricyclics affect many neurotransmitters, or brain signal chemicals, the newer ones affect only three: serotonin, norepinephrine and dopamine systems. The beauty of SSRI's is that because side effects are substantially fewer, they are easier and more safe for physicians to prescribe and for patients to use, Aebi explains. Over the last eight years SSRI's such as Zoloft, Paxil, and Prozac have become household names. However, each drug is unique, as is each individual taking them. It is crucial that physicians work with their patients to find the medication most suitable. For instance, explained Aebi, Prozac might cause agitation in one, but might be suitable for someone else. Paxil might cause drowsiness in some patients, but in others it might effectively treat their anxiety. As the patients will feel the immediate side effects of the medication first, such as nausea and a lowered libido, and the mood elevation later, they might get discouraged and want to try another medication. It could take up to five weeks before any therapeutic effects are noticeable, notes Shaw. "We see too many prescriptions for too many changes too quickly. You won't see dramatic results overnight. That's just the way they work," says Aebi," They are not harsh in the body. ... We're trying to work slowly to have the system readjust itself." "They are very gentle and very slow in the brain," Aebi explained. "We're not just putting in a vitamin and all of a sudden replenish the body ... we're working with neurotransmitters that have to reestablish an electrical pathway and network. It takes some time for the body to do that. That's why they are very gentle and have less side effects." The risk of a drug overdose or toxic side effect with the SSRI's is nearly non-existent so visits to the emergency rooms have decreased, she says. Follow-up visits to the doctor once a patient is on the medication is scheduled in terms of weeks, rather than days as it was with the tricyclics. There will always be side effects to pharmaceuticals, no matter what the drug companies do to refine the medication, says Aebi. "We have neurotransmitters all over our body," she says. "Anytime you put any chemical in the body „ whether it be health food chemical or a manufactured chemical from a drug company „ it's going to affect some other system in your body. Aspirin affects blood; you may take it for one specific thing, but it is affecting a lot of other areas in your brain and body." Depression and Hormones Research on depression and brain chemistry is starting to examine the role hormones play in women approaching menopause. While some research indicates that the decline of estrogen as a woman goes through her perimenopausal transition might trigger a mood disorder, other research indicates that there is no decline and that mood disorders in this time period of a woman's life have more to do with life situation, says Babcock. "Hormones may have an effect," she says, "but there is more to it. As a gynecologist, I think of it as parallel tracks and not necessarily related. So you have your female hormones and they may make you more miserable or less miserable but the depression track is a different track and it's going to go along regardless of what is happening hormonally." However, Aebi disagrees, "up until the last 5-10 years we didn't even consider horomones and mental health diseases nearly as much. I think medicine has geared itself toward men and men's diseases for so long that we're just coming around and seeing that we haven't treated women the same." At this point, Aebi believes, hormone levels are not as useful as predictors of depression. It is more, she believes, that there is a connection with depression. This is the "next place we really need to look", she says.
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