THE UNDERTREATMENT OF DEPRESSION

Recently the Journal of the American Medical Association published a landmark consensus statement which was formulated by an expert panel of the National Depressive and Manic-Depressive Association. This panel came to the conclusion that there is a significant condition prevalent in America today which results in considerable loss to the economy and personal suffering, and that is the undertreatment of depression.

In spite of the fact that mental depression is more treatable today than at any other time, it still is the case that a significant percentage of the population suffers depressive symptomatology. Some of the suffering is due to undertreatment of depression by some psychiatrists and many internists and family practice physicians, and much of the depression continues to be undiagnosed.

Some of the depression continues to be undertreated by the older anti-depressives, which are less potent and carry more side effects. Unfortunately, the older anti-depressants are cheaper and therefore the profitable managed care corporations prefer to use them, in their campaign of cutting medical costs and increasing the salaries of the CEO's. At the same time, these corporations are accumulating cash reserves in the billions, which they use to buy other managed care corporations instead of reducing premiums and adding benefits.

Much of the ongoing depression is undiagnosed because the symptoms are atypical and covered over by alcoholism and drug-abuse. On the other hand, many people use denial and rationalization, telling themselves and others that their feelings are not out of the ordinary and appropriate to the situation. They think their moodiness, anxiety and tension relate to the stressful world we are living in. Many problem drinkers rationalize their drinking as social and tension-relieving.

Other depressed persons have sleep and appetite disorders. Some people have trouble falling asleep and others wake up too early. Some depressives want to sleep all the time and feel a lot of bodily inertia, going to physicians for what is called "chronic fatigue syndrome". In most cases, CFS is undiagnosed mental depression.

We are learning that for the most part, mental depression is due to a familial (genetic) predisposition and is due to neurochemical imbalance. If the brain chemistry is not in balance, mood swings are liable to occur, most often in the direction of negativity, which includes pessimism, discouragement, indecision, inability to concentrate, poor interpersonal relationships, withdrawal, moodiness, irritibility and being temperamental.

If the mood swings the other way, there may be periods of increased activity, pressure of speech, racing thoughts, grandiosity, hypersexuality, pacing, inability to sleep and loss of judgment, which may include spending sprees and excessive gambling. Sufferers may fall in and out of love frequently and crave sexual expression. This symptom complex is called hypomania or mania, depending on how severe.

Both mania and depression can lead to psychosis, or loss of contact with reality, and sometimes hospitalization is warranted to prevent suicide or self-destructive behavior. Hospitalization may also be a way to start adequate medication or the last resort of electroshock therapy. In spite of misconceptions to the contrary, ECT (electro-convulsive therapy) is the most effective therapy for deep and intractible depressions and does not cause permanent brain damage.

Other indications of untreated depression are eating disorders, anorexia and bulimia, and excessive obesity. In these cases, as with alcohol and addictive drugs, food craving is an attempt to relieve the underlying tension associated with neurochemical imbalance. This underlying tension also causes the craving connected with the nicotine addiction of cigarette smoking. Other addictions associated with underlying depression include caffeine addiction. Caffeine addicts drink upwards of ten to twenty cups of coffee a day, or a corresponding amount of cola beverages, such as Coke and Pepsi.

Other addictions include running and gambling. Runners run for the 'runner's high' and gamblers seek the thrill of the big win, which constantly eludes them. Some people are sex addicts, requiring sex contacts daily or several times a day. All the addictions are attempts to satisfy an excessive and pathological craving. As one of my insightful patients once told me, "You can never get enough of what you don't really need."

Persons with symptoms of depression and/or neurochemical imbalance are urged to seek a consultation with a psychiatrist, who is in a position to prescribe drugs, recommend hospitalization or advise psychotherapy. Psychiatrists, by virtue of their medical training and experience are in a position to differentiate psychological from neurochemical causes. They may recommend psychotherapy by a clinical psychologist or psychiatric social worker, but I think it is better when one professional can perform the entire treatment, if both psychotherapy and medication are necessary. This way the psychiatrist gets to know the whole person over time, in depth and complexity, and an ongoing rapport is developed which is essential to successful treatment.

Treatment may be short term or long term, depending on the individual case and each person is unique. For the most part treatment is beneficial and worth the time, effort and expense. Hopefully the recent publicity about the undertreatment of depression will help many to seek and get the help they need.

Dr. Bloom is Clinical Associate Professor of Psychiatry, Wayne State University School of Medicine. He practices in Grosse Pointe Park Michigan. Email-vbloom@comcast.net. URL- victorbloom.com