DEPRESSION OR ADHD OR CHRONIC FATIGUE?

Victor Bloom MD

Just when we think we know, there comes new information. Or misinformation, or disinformation. What I am talking about are new findings, which are muddying the waters of what depression is and how it is to be treated.

Depression is basically unaccountable sadness, unhappiness, discouragement, pessimism, hopelessness, anguish and despair. It is often accompanied by sleep and appetite disturbances, a slowness of movement and thought, obsessive and worrisome thoughts, irritability, inability to concentrate, uncontrollable sobbing and suicidal thoughts. Estimates of upwards of 30% of the population are said to be prone to it at one time or another in their lives, and there is a strong familial tendency. It is also accompanied by poor interpersonal relationships and substance abuse.

It is estimated that depression not only causes much suffering, but inefficiency and loss of work costs society billions annually. Adults with depression are not good parents or spouses. It is really a terrible disease and treatment, up to now, has been largely unsuccessful. Now there are a host of medications which are greatly ameliorative, and these chemicals restore balance to the underlying neurochemical imbalance which is at the root of the difficulty.

Now comes clinical research studies that purport to say that much of what is called depression is really adult attention deficit (hyperactivity) disorder (ADHD), previously called ADD. This had previously been reported only in children, but now some researchers and clinicians are saying that when these children grow up, they still have ADD and these are some of the symptoms of depression. But the treatment for ADD is Ritalin, and that is an old stimulant-anti-depressant which is similar to amphetamine, ('speed'), which used to be used for depression, but which was discontinued because of the tendency to habituation and addiction. But it remained the treatment-of-choice for ADD, which, by the way, used to be called MBD (minimal brain damage).

It is clear that ADD has been over-diagnosed and Ritalin over-prescribed, as federal funds (social security) were made available for those with the diagnosis. Many pediatricians and child psychiatrists fell into lockstep diagnosing this condition, with the best of intentions. There is no doubt but that Ritalin helped those few who really had the disorder.

A condition which further muddies the waters is CFS (chronic fatigue syndrome), which some epidemiologists (infectious disease specialists) say is due to a virus. So some people are glad to learn that all they have is a bad case of the flu, and that they aren't really depressed at all, and there is no psychiatric stigma or psychological explanation. All they need is some time and antibiotics, and they will feel better. But the thing is that many bouts of mental depression, due to neurochemical imbalance, also get better, spontaneously, in a few months, so it is never clear whether tincture of time was the therapeutic agent, or whatever medication was taken at the time. The epidemiologists claim that they have antibody tests which demonstrate infection by a particular virus, but it is difficult to associate the virus with the clinical state.

Years ago some doctors thought that a prolapsed mitral valve, causing a heart murmur, was at the root of anxiety in many people, and they were treated with digitalis instead of tranquilizers. But that theory faded away and was eventually disproven, as so many others have been, and will continue to be.

Fatigue and malaise and multiple somatic complaints continue to accompany depression, but is the depression primary or secondary? Certainly bodily discomforts and incapacity are a legitimate and regular source of depressed feelings. Who would not be depressed from chronic headache or backache or muscular aches and pains, or real incapacity due to heart disease or stroke?

Unfortunately, it is sometimes hard for a clinician to distinguish between real physical illness and mental hypochondria (imaginary illness). Such complicated cases are sometimes the bane of the diagnostician's existence, and the doctor must order extensive tests and studies. Sometimes, unfortunately, such complicated patients are dismissed as 'crocks' and not given the time of day or the real compassion and empathy that they need. Real empathy is based on understanding, and sometimes understanding is elusive, despite the best training and experience of the physician.

So sometimes second and third opinions are in order, and sometimes various treatment modalities have to be considered and tried. We have to accept the fact that every person is unique and complex and that diagnostic categories are nothing but generalizations. People cannot be pidgeon-holed.

In the wake of all this confusion as to what constitutes depression, comes an herbal remedy from Germany. It's trade name is "Kira" and it is an extract of a flower called, St. John's Wort. The chemical name fo‡r the active ingredient is called "Hypericum" and since it is an herb, it is not tested by the FDA (Federal Drug Administration). Still, it has been used in Germany for years and claims to have very beneficial effects for symptoms of depression. It has similar actions to Prozac and the SSRI's (selective serotonin reuptake inhibitors) and minimal side effects.

It can be bought over the counter and costs about half the price of Prozac. Presently, Arbor Drugs is out of it, the demand is so great. Time will tell whether "Kira" will be a substantial help for nervous disorders such as depression, but in the meantime, what we are learning is that each person has his own mental and emotional profile, all of which is mediated, basically, by neurochemicals, and some of the imbalances are at least someone correctible by pharmacologic agents, which now include herbal remedies. Can millions of Germans be wrong? They were wrong before, but it would be nice for them to be right, now