Depression: Dispelling Dispair
By Anne H. Rosenfeld
Exercises: J. Geffen
1. The "black dog" of depression claims more than 9 million adult victims in
the United States yearly, driving up to 15 percent eventually to self-destruction.
It stalks people of all ages, in all walks of life, but seems to prefer the
downtrodden and women. Depression has hounded Abraham Lincoln, Winston
Churchill, Sylvia Plath, Ernest Hemingway and Thomas Eagleton, as well as
Saul and Nebuchadnezzar. It can strike once in a lifetime, disrupt a normal life
with intermittent months of misery and incapacitation or become a continuous
burden for years. Intolerable downs may alternate with manic highs or, more
commonly, be unpunctuated by mania. Depression's symptoms can be purely
psychological or a mix of mental and physical complaints.
2. What most people call "depression" is actually a group of mood disorders
with different symptom patterns and degrees of severity. Experts are still
thrashing out how many there are; how to distinguish them; where to draw the
line between clinical disorder and the intermittent sadness and grief of normal
living; and how best to treat the genuinely depressed.
3. Historically, the black dog has been fought with whipping, bloodletting,
exorcism and the spirit soothing of music, baths and gentle words. But until
some 30 years ago, psychotherapy and electroconvulsive therapy (ECT) were
the major options for lifting people out of profoundly melancholic states. Then
began the era of modern psychopharmacology and the development of drugs
that control the manifestations of depression, although not the underlying
malady.
4. Since that time, numerous psychotherapies and drugs as well as ECT have
remained the major treatment options for severe clinical depression, providing
a rich array of techniques for pulling desperate people out of the "slough of
despond." But the very diversity of these treatments raises a host of questions.
With approximately 130 types of psychotherapy, more than 30 antidepressant
drugs and a variety of ways of administering ECT, who should get what, when,
how much and for how long? The search for answers has helped make
depression treatment safer, more effective and even more responsive to
individual needs.
5. Among depression treatments, ECT is unquestionably the most controversial. It is powerfully effective in averting suicide and treating recalcitrant
cases of extremely severe depression. Yet its still-contested side effects make it
likely to remain a treatment of last resort, or emergency first resort, for a small
minority of the severely depressed.
6. Psychotherapy and drugs, too, have strong proponents and detractors,
although disagreements are usually far less intense than those involving ECT.
The advocates of drug treatment cite its success in relieving many symptoms of
severe depression. Some claim that drug treatment is effective with 60 to 80
percent of depressed patients. The drugs work, it is argued, because they
correct imbalances in brain chemicals that accompany and, some believe, cause
depressive symptoms. While no one would claim that today's depression drugs
cure depression any more than insulin cures diabetes, the hope persists that
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with better understanding of the biological defects underlying depression, real
cures -- and even prevention -- may be possible.
7. On the psychotherapy side there is also a growing body of data showing
significant symptom relief for certain types of depression, although, again, no
cure. (Claims for treatment effectiveness also run up to the 80 percent range.)
While conceding that drugs are essential for the very severely depressed, some
advocates of psychotherapy would argue that it is preferable for the mildly to
severely depressed. Beyond symptom relief, it can offer greater self-esteem,
self-understanding and social skills -- all essential, they believe, in coping with
life's stresses and warding off or minimizing future depressive episodes.
8. These views are being put to the test in treating major depressive disorder
(MDD), a type of serious clinical depression for which both drugs and
psychotherapy are used, singly and in tandem. Its symptoms are both physical
and mental, leading many people to seek medical care when they first become
ill. Consider the case of Henry Greene, a composite of many patients with
MDD:
9. Greene, a 36-year-old lawyer, wrestled with his symptoms for months
before seeking his doctor's help. His first complaints were physical: His sleep
was fitful, often ending at 3 or 4 a.m. Food was unappetizing, and he had lost
15 pounds in the past few months. His sex life was practically nil. Marge, his
wife, even in her slinkiest negligee, didn't turn him on. Nor did Cathy, his
sometime lover. Greene moved and talked slowly, his voice a weary monotone.
Gravity seemed to pull too hard in .his corner of the world, and he could barely
fight it.
10. When Greene finally Jet down his guard, he revealed his deeply
depressed mood: "I look successful. I've got it all. But I feel like a sham, a
failure. I'm a third-rate lawyer, husband, father, lover, and I'm doomed to stay
that way. No matter what I do, there's no joy, no pleasure. Just a treadmill of
duty and guilt. I'm exhausted. What's the point of continuing?"
11. How should patients such as this be treated to assure the speediest, safest
and most enduring recovery? There is no clear-cut answer yet. But as a
practical matter, the choices patients make in seeking help for depression may,
in part, determine the type of treatment they receive. For example, Greene's
decision to visit his Internist helped to tip the treatment decision 80 in favor of
drugs, probably the most common treatment for MDD. (Had he gone to a
psychologist, the treatment probably would have been psychotherapy, although
psychologists and physicians sometimes work together to provide both
psychotherapy and drug treatment. With a psychiatrist he might have received
drugs, psychotherapy or perhaps both.)
12. Among the antidepressant drugs, the tricyclics such as Tofranil or Elavil
are usually chosen .first. It may take about two weeks for the drugs to take
effect, and Greene will have to endure some annoying side effects before he
senses any relief. But if he responds well, he may then improve quickly,
sleeping and eating better and becoming less withdrawn and morose. If he does
not respond, or reacts badly to the drug, another family of antidepressants can
be used: monoamine oxidase inhibitors (MAOIs) such as Marplan, Nardil or
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Parnate. But with these drugs, patients must restrict their diets to avoid harmful
side effects. For patients who cannot tolerate or respond well to these drugs,
still others are available.
13. Whichever drug is chosen, Greene probably will have to continue medication for three to six months to control the current episode. Further, since
MDD tends to be recurrent, and may return with increasing frequency if
untreated, many MDD patients require long-term "maintenance" drug treatment
to prevent the return of symptoms.
14. If Greene does well on drugs, pulls out of his depression and is free of
the symptoms that brought him to his doctor's office, is he now out of the
woods? Not necessarily. Despite drug treatment, he may be unable to handle
the multiple stresses his disorder has exacerbated and may relapse.
15. Many practitioners treating patients like Greene prefer to combine drugs
and psychotherapy. As one psychiatrist puts it, "A patient on tricyclics may
wake up one day and feel much better. But then he finds he's got to get the
loose ends of his life together. The depression cost him time, relationships and
maybe his job. He may need drugs to bring him sufficiently out of the doldrums
to face real-life problems, but psychotherapy may then help him reintegrate his
life."
16. How do the two approaches fit together in treating Greene's MDD and
other types of depression? Frederick Goodwin, a psychiatrist and depression
researcher at the National Institute of Mental Health (NIMH) views depression
in all its varieties as a spectrum of disorders for which multiple approaches are
needed. In his opinion, the most severe forms, which involve biological
changes in the brain (and physical as well as mental symptoms) initially require
drug treatment. Later, during or after drug-induced recovery, psychotherapy
can enhance psychological and social functioning and perhaps lessen the
likelihood of relapse, in part by encouraging patients to comply with drug
treatment. The intermediate forms of depression generally benefit from a mix
of psychotherapy and drugs. The milder and briefer forms probably are best
treated by psychotherapy alone, particularly if physical symptoms are absent:
In Goodwin's experience, the prime candidates for the drug-plus-talk approach
have physical and mental symptoms and "long-lasting troubled relationships;"
17. But suppose Greene had sought out or been referred for psychotherapy
with no drug treatment? How would he have fared? This issue is far from
resolved. but there's evidence that, despite the presumed rather strong
biological component in MDD, certain types of psychotherapy alone can
effectively treat some MDD patients' acute episodes, perhaps as well as or
better than drugs.
18. Considering all types of depression, psychotherapy is probably the most
commonly used treatment. Particularly widespread are the psychodynamic
types of psychotherapy, many of which, based on the theories of Freud or his
followers, emphasize understanding unconscious motivations and the
childhood origins of adult problems. Such therapies include both
psychoanalysis and briefer, less intensive approaches (the weekly "5O-minute
hour"). However, psychodynamic psychotherapies' effectiveness in treating
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MDD has not been well established, in part because they are difficult to
standardize for study.
19. Far more encouraging results have been obtained in the past decade or so
with more readily studied, highly structured short-term psychotherapies, most
based on cognitive and/or behavioral approaches to depression. Early results
from a growing number of studies suggest that some of these therapies can
have positive, often long-lasting effects on severely depressed patients who,
like Greene, are not manic-depressive, psychotic or too withdrawn to help
themselves recover.
20. Unlike psychodynamic psychotherapies, most cognitive and behavioral
therapies trace their lineage to B.F. Skinner or to one of the cognitive
psychologists, such as Albert Pandura. Accenting the here and now rather than
the past, most of these therapies emphasize teaching patients -- singly or in
groups -- how to behave in ways that increase rewarding experiences.
21. Two promising group therapies for MDD are those developed by
psychologist Lynn Rehm at the University of Houston, and by psychologist
Peter Lewinsohn at the University of Oregon. Rehm's approach focuses on
problems of self-management, that is, the way people organize their behavior to
work for long term goals. Depressive people, Rehm believes, accentuate
negative events and focus on short-term consequences of behavior. They also
judge their behavior harshly .and are quick to take blame for failures but not
credit for successes. The therapy trains people to monitor, evaluate and reward
their behavior more realistically.
22. Working with small groups of depressed women, usually meeting for 6 to
12 weekly 1 1/2 hour sessions, Rehm and coworkers have conducted studies to
assess bow well the treatment works. In the first study, subjects were taught to
monitor what they think and do, make their goals more realistic, give selfpraise and -blame more accurately and reward themselves for things done right.
They were also assigned homework. Compared with untreated patients or those
receiving "nonspecific group therapy," patients who received self-management
therapy showed the most improvement and maintained it for at least six weeks,
23. In a later study using more stringent criteria for MDD, the researchers
compared the full treatment package with selected components, such as selfmonitoring alone or self-monitoring plus self-evaluation. While all groups did
better than untreated patients, no consistent differences were found among
treated groups. Even self-monitoring alone could aid in overcoming depression.
In some preliminary studies, other researchers, using Rehm's full-treatment
package alone or with a tricyclic antidepressant, found equal improvement after
three months, although those getting the combined treatment responded faster.
24. The short-term group treatment developed by Lewinsohn and his
colleagues focuses on the passivity of depressed people -- the vicious cycle of
trying less and getting less that minimizes rewarding experiences. His treatment
is often referred to as the "pleasant-activities" approach, since it uses a variety
of tactics to get patients to increase their activities. These include "assertion,
relaxation training, daily planning~ increasing pleasant activities and time
management training." Cognitive procedures are also used to help people deal
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with stressful situations. The techniques have been incorporated into a
treatment package known as the "Coping with Depression" course. It is
conducted like any other course, complete with textbook (Control Your
Depression) and a workbook. One controlled study has shown that the.12session course -- whether given as a class, as individual tutoring or as a home
study program with phone contact -- produced gains that were maintained after
six months.
25. This sampling of recent research underscores the uncertainties that
remain in assessing what is the "best" way to treat MDD for patients like
Greene. 8ut it is already clear that he and other depressed people have many
alternatives among treatments that are rapid, effective and suited to their
specific needs.
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Questions should be answered in your own words, in English, unless otherwise
indicated.
Complete the sentences below.
1.
2.
In the U. S.A. the number of people yearly reported as suffering from depression
is about____________________________________________________
Every year about _______________________ grown-up people suffering from
depression end up as suicides.
Answer the question below,
3. Name some famous historical personalities reported as suffering from
depression.
Answer: __________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
Answer the question below in English.
4. What forms does depression assume when it becomes manifest?
Answer: _________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
Choose the best answer.
5. Paragraph 2 would imply that human existence is by definition
a. conducive to clinical depression.
b. a clinical affair.
c. Fraught with sorrow.
d. free from sorrow.
6.
.
Answer the questions below in English.
List some of the remedies - paragraph 3 - employed in the past, in an attempt to
combat depression.
a. _______________________________________________________________
b. _______________________________________________________________
c. _______________________________________________________________
d. _______________________________________________________________
e. _______________________________________________________________
Depression/8
7.
How does the approach adopted some thinly years ago differ from the previous
practices used to treat depression (paragraph 3)?
Answer: _________________________________________________________
________________________________________________________________
________________________________________________________________
8.
List some of the arguments for and against the use of ECT (electric shock
treatment)?
Answer: __________________________________________________________
_________________________________________________________________
_________________________________________________________________
Answer the question below in Hebrew.
9. In what essential sense does psychotherapy differ from drug treatment?
Answer: ___________________________________________________________
__________________________________________________________________
__________________________________________________________________
Answer the question below in English.
10. To what do the advocates of drug treatment attribute clinical depression?
Answer: ________________________________________________________
_______________________________________________________________
_______________________________________________________________
Complete the sentence below.
11. Eyen the advocates of psychotherapy - paragraph 7 - would probably admit that
the severely depressed _____________________________________________
_______________________________________________________________
Answer the question below in English.
12. In what cases is psychotherapy combined with drug treatment?
Answer: _________________________________________________________
________________________________________________________________
________________________________________________________________
Answer the questions below in Hebrew
13. On what grounds do some doctors - paragraph 7 - recommend psychotherapy
for the mildly depressed rather than drug treatment?
Answer: _________________________________________________________
________________________________________________________________
_______________________________________________________________
14.
Describe the stages typical MDD cases may go through - paragraphs 9-10 –
before seeking medical advice.
Answer: _______________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
Depression/9
Choose the best answer.
15. Paragraph 11 suggests that the treatment for MDD, recommended by one or
another doctor, may vary in accordance with the doctor's field of specialization;
thus,
a. an internist would probably recommend _____________________________
b. a psychiatrist might suggest _______________________________________
c. while a psychologist might opt for __________________________________
16.
It is suggested in the text that MDD cannot in fact be
a. diagnosed. b. treated.
c. neglected. d. cured.
Answer the question below in Hebrew.
17. What particular fact makes the notion that MDD responds only to drug treatment
rather questionable?
Answer: __________________________________________________________
_________________________________________________________________
_________________________________________________________________
Complete the sentences below so as to accord with paragraphs 17-20.
18. a. Freud's disciples would obviously not recommend _____________________
for the severely depressed.
b. The ones least likely to benefit from psychotherapy are _________________
_____________________________________________________________
Answer the question below in Hebrew.
19. What particular aspect of their behavior - paragraphs 21-22 - do depressive
people tend to emphasize?
Answer: ________________________________________________________
_______________________________________________________________
_______________________________________________________________
Answer the question below in English.
20. What would the writer consider the best way of treating severe depression?
Answer: ________________________________________________________
_______________________________________________________________
_______________________________________________________________