It is perhaps its invisibility that places major depression among the more insidious disorders that afflict humankind. You can neither spot it on an X-ray nor detect it with a toxicology screening. Medical professionals can find it difficult to diagnose.
To make matters worse, a lingering stigma too often attaches to those who have depression, further hindering diagnosis and treatment. This January's Super Bowl offers one recent example of that stigma's power. When the Oakland Raiders' Barret Robbins began behaving oddly the week before the big game, his fellow players came down hard on him.
"Whatever rock he came up from under, he can stay there," one of his teammates told NFL Weekly News at the time. Robbins, who has bipolar disorder, spent Super Bowl Sunday in a hospital. Robbins' experience is an extreme one, given the stresses of life in the spotlight. But it shows the kind of condemnation that many people with mood disorders encounter.
"This stigma is partly to blame for the fact that so many people who have major depression don't get treatment," says Julie Totten, founder and president of Families for Depression Awareness, a nonprofit support group. "People don't talk about depression the way they might talk about diabetes or heart disease or cancer treatment. It's easier to blame feelings of depression on other people or situations in life than it is to recognize an internal disease that may have been going on for years and years."
An institutionalized version of this stigma can be seen in the coverage caps many health insurance companies place on treatment for mental illness, Totten says.
"If an HMO capped care for diabetes or heart disease at 20 visits, people would be screaming," she says. "But they can get away with capping mental illness because no one wants to talk about it."
Some states have passed so-called parity legislation, requiring HMOs to give equal coverage for mental illness claims, she says.
"That's a good start, but in most of the country people with mental illness have to deal with both the illness and the stigma that makes it that much harder to face."
Depression affects about 10% percent of Americans at some point in their life. About 18.8 million people suffer from depression, according to the National Institute of Mental Health (NIMH). Major depression is the leading cause of disability both in this country and in the world at large. Women worldwide have about a twofold greater risk of having depression than men.
So does anyone ever really get over depression?
"Recovery is highly variable from patient to patient," says John Barnhill, MD, an associate professor of psychiatry at Weill Medical College of Cornell University. "Some people respond to treatment well and are through an episode in six months. Some patients with severe depression may need constant supervision to avoid relapse."
Barnhill says treatment usually includes medication and talk therapy with a mental health professional.
"Depression is a very treatable disorder, but it is also a recurring disorder," says Gerald I. Metalsky, PhD, associate professor of psychology at Lawrence University in Appleton, Wis., and executive director of the Anxiety, Stress, and Depression Center there. "Once you've had one major depressive episode, your chances of having another is high."
Symptoms of depression include sad mood, loss of interest or pleasure in activities that were once enjoyed, change in appetite or weight, difficulty sleeping or oversleeping, physical slowing or agitation, energy loss, feelings of worthlessness or inappropriate guilt, difficulty thinking or concentrating, and recurrent thoughts of death or suicide, according to the NIMH.
There are three types of mood disorders, and each requires its own treatment.
Major depressive disorder -- This refers to episodic, primary, severe depression lasting at least two weeks. This diagnosis is made using a set of criteria when a person has five or more depressive symptoms and daily impairment in functioning.
"We have very good treatments for major depressive disorder," says Metalsky. "With medication and cognitive-behavioral therapy, we see a success rate of 70% to 80% within 10 to 15 sessions of therapy, though sometimes more sessions are needed."
Dysthymic disorder -- This chronic but less severe form of depression is diagnosed when depressed mood persists for at least two years. This disorder usually begins early in life.
"Treatment is similar to that of major depressive disorder, but it is a more slippery disorder and in some ways requires greater vigilance," says Metalsky. "The symptoms aren't as severe, but they take longer to treat and recur more easily."
Bipolar disorder -- Depression alternates with mania in this disorder, which is characterized by abnormally and persistently elevated mood or irritability and symptoms including overly-inflated self-esteem, decreased need for sleep, increased talkativeness, racing thoughts, distractibility, physical agitation, and excessive risk taking.
"Medication is needed for bipolar patients, usually lithium or Depakote along with an antidepressant," says Metalsky. "Talk therapy works well here, too, since many bipolar patients spend a lot more time depressed than they do in the manic stage."
Relapse rates are high for all types of mood disorders, Metalsky says, but in therapy people can learn skills that they can take with them to combat depressive thoughts and habits. These skills can in turn help a person reduce the frequency of major depression recurrence.
John Casey is a freelance writer in New York City.
Published May 5, 2003.
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