Depression Is Not Just Sadness - and It Shouldn't Be Ignored

Depression can afflict anyone, regardless of fame, fortune or achievement. Film stars like Brooke Shields, Uma Thurman, Ashley Judd, Winona Ryder, Jim Carrey, Ben Stiller, and Richard Dreyfuss have been treated for it. Abraham Lincoln suffered depression throughout his life; British Prime Minister Winston Churchill called it his "black dog."

"Depression is a neuropsychiatric medical condition," says Thomas W. Heinrich, MD, an Assistant Professor of Psychiatry and Behavioral Medicine at the Medical College of Wisconsin. "It doesn't matter how famous or prominent you are, what kind of car you drive or what tax bracket you're in. Anyone can still suffer from major depression."

Depression is not synonymous with sadness, he emphasizes. "Sadness is an emotion, and it's usually time-limited and proportionate to the cause." It can be triggered by grief, loss, or disappointment. "Only rarely is such sadness accompanied by a feeling of hopelessness, worthlessness, guilt, and loss of interest or pleasure in activities, which are some of the characteristics of depression," Dr. Heinrich says.

"There are good reasons to feel sad," he adds. "There's never a good reason to suffer from major depression. Major depression is a pathological disease state that has adverse health consequences - and it should be treated and not ignored."

Symptoms of Depression
The National Institute of Mental Health (NIMH) provides the following list of depression symptoms, noting, however, that not everyone who is depressed experiences every symptom:

• Persistent sad, anxious or "empty" mood
• Feelings of hopelessness, pessimism
• Feelings of guilt, worthlessness, helplessness
• Loss of interest or pleasure in hobbies and activities that were once enjoyed, including sex
• Decreased energy, fatigue, feeling "slowed down"
• Difficulty concentrating, remembering, making decisions
• Insomnia, early-morning awakening or oversleeping
• Appetite and weight loss; overeating and weight gain
• Thoughts of death or suicide, suicide attempts
• Restlessness, irritability
• Persistent physical symptoms that do not respond to treatment, such as headaches, digestive disorders and chronic pain

Depression is common and pervasive. The NIMH estimates that in any given one-year period, 9.5% of the population, or about 20.9 million American adults, suffer from a depressive illness. The three most common types of depression are:

Major depression - Patients experience a combination of symptoms (see above symptom list) that interfere with the ability to work, study, sleep, eat, and enjoy once-pleasurable activities

Dysthymia - A less severe form of depression, involving long-term, chronic symptoms that do not disable, but keep one from functioning well or from feeling good.

Bipolar disorder - Also called manic-depressive disorder, it is characterized by cycles of extreme elation and severe depression.

Some types of depression seem to run in families, but it can also occur among people with no family history.

Like other mental illnesses, depression is often still stigmatized and inappropriately viewed as a sign of personal weakness, Dr. Heinrich says. That may be why many patients, men especially, refuse to acknowledge their condition and fail to seek adequate medical care for it. More and more men have begun to come forward lately, however, according to a February 2006 Newsweek cover story on men and depression. It is estimated that 6 million American men will be diagnosed with the condition this year.

Men, Women, and Depression
Women experience depression more often than men, but a 2003 study by the National Institutes of Health (NIH) found the gap between men and women continuing to narrow. It said women who have had at least one episode of depression currently outnumber men 1.7 to 1. Forty to 50 years ago, the ratio was three to one, and 10 years ago, it was two to one.

"Many hormonal factors may contribute to the increased rate of depression in women," NIMH says, citing "such factors as menstrual cycle changes, pregnancy, miscarriage, postpartum period, premenopause and menopause. Many women also face additional stresses such as responsibilities both at work and home, single parenthood, and caring for children and for aging parents."

In his practice, Dr. Heinrich has noticed that men and women often express different symptoms. "Women more often mention loss of appetite, inability to sleep and fatigue as symptoms of depression," Dr. Heinrich says. "Men tend to express more irritability and anger, possibly because they feel more vulnerable to the stigma associated with a mental illness." Men, especially, also may hide their depression by working long hours or using alcohol or drugs.

The rate of suicide in men, however, is four times that of women, although more women attempt it. In fact, after age 70, the rate of men's suicide rises, reaching a peak after age 85. "Elderly white men represent one of the highest risk groups for suicide in population studies." Dr. Heinrich says.

African Americans are 40% less likely to experience depression than Hispanics or Caucasians, the 2003 NIH study said. On the other hand, blacks who develop the disorder are 30% more likely to suffer lasting or recurring depression.

People living in poverty are also at increased risk; they are nearly four times as likely to suffer chronic depression as affluent people, the study reported.

Children and the Elderly
Children can also have depression, Dr. Heinrich notes, citing one study that showed that 3% to 5% of children are depressed, with boys affected more than girls. By the onset of puberty, however, twice as many girls experience depression than do boys. (Dr. Heinrich's practice focuses only on adult patients.)

Elderly people experience depression, too, and it should not be considered a "normal" part of growing older and frailer. As with other age groups, major depression is not merely feeling sad; it's a major medical disease. "In fact," Dr. Heinrich says, "many elderly patients with depression do not subjectively complain of feeling sad. They may instead complain of physical and cognitive deficits. Elderly patients may also experience what's sometimes called 'depression without sadnesss' - an emotional flatness, in which they have no feelings, no interest in anything, apathy."

One of the areas of research that interests Dr. Heinrich and others in the field is the toll depression can take on physical health. Recent scientific studies have shown that depression can affect the outcome of such conditions as heart disease, stroke, diabetes, and cancer.

"We're learning much more about the consequences depression can have on patients' medical outcomes," he says. "For example, patients with depressive disorders who suffer myocardial infarctions (heart attacks) are three to four times more likely to die within 12 months than those without depression. The risk depression poses does not only occur after a patient develops heart disease. Studies have shown that patients with no known cardiovascular disease are twice as likely to develop cardiovascular illness in the future if they have a history of major depression."

A study published in February 2007 in the Annals of Internal Medicine showed that, in heart failure patients, depression is as great a risk factor as high cholesterol, hypertension and even the ability of the heart to pump blood throughout the body. Yet another February 2007 study, in the Archives of General Psychiatry, showed that depression's physical signs, especially fatigue and loss of appetite, may contribute to thickening arteries, an early sign of cardiovascular disease.

"We also see reciprocal patterns of symptoms in patients with co-morbid medical illnesses and depression, especially among elderly patients," Dr. Heinrich says. For example, a depressed mood tends to amplify one's perception of pain, making the pain worse. And the presence of pain can make depression worse."

There is good news about depression, however.

"Depression is a very treatable," Dr. Heinrich says, "with better treatment outcomes compared with other medical diseases."

For more information on this topic, see Part 2 of Dr. Heinrich's discussion, Depressed Patients Who Seek Help Usually Respond to Treatment.

Barbara Abel
HealthLink Contributing Writer

Thomas W. Heinrich, MD, practices at Froedtert Hospital, the Medical College of Wisconsin Behavioral Health Center in Tosa Center on Mayfair Road, and Community Memorial Hospital in Menomonee Falls.

MCW Health News presents up-to-date information on patient care and medical research by the physicians of the Medical College of Wisconsin.