The dark underworld of despair
In his harrowing personal account of depression, In the Jaws of the Black Dogs, Globe and Mail writer John Bentley Mays recalls an interview with a psychiatrist that began with “the unrolling of the dolorous carpet of tales… I listed at length symptoms common to virtually all depression — though I did not know then that my complaints were anything but unique. I complained of a decline in vital energy; a weakened ability to enjoy the fulfilment of needs or of aesthetic desire. Even the most reasonable goals had become difficult or impossible to set, and, when established, impossible to fulfil. I was continually shadowed by the sense of being busy going no place; most psychiatric patients, I imagine, are shadowed by the same feeling.
“I complained about sleep troubles, eating troubles. I found myself avoiding all but the most urgently necessary contact with other people. The ill feeling that, for some depressives, does not get much worse than a generalized unhappiness would in my case often degenerate into overwhelming self-loathing, climaxing in sudden, surprising relief, or thoughts of suicide.”
Welcome to the dark underworld of major depression. As Mays suests, his symptoms are in some respects typical of depressives everywhere; what makes his experience special is his ability to recreate it in such vivid, wrenching detail, to draw it, unflinchingly, from the bitterest caverns of memory. It’s a mesmerizing account, the unfinished tale of a man’s struggle through a long vale of shadows and tears toward a very uncertain future.
In the Jaws of the Black Dogs offers no undue sentiment, and no happy ending. “Even if I could fool myself, and some readers, into believing that all’s well,” he writes, “doing so would only confirm the most mischievous superstition about depression: that all its victim needs is a good job, an interesting career, a loving family, and all will be well… None of us wishes to believe the truth: that depression is the most obstinate experience this side of malignancy and death, a deadly presence in language and thought as inextricable as an inoperable tumour.”
Mays paints a grim picture, though one not entirely without hope — at once a fascinating report from the ragged frontiers of chronic depression and a superb reminder of just how shattering depression can be. Mays’ book is also a reminder of psychiatry’s limits — for the moment at least — however beneficent the results of its interventions may be for most people. That’s something that may not get a lot of play in Black Dogs, but it’s true: There are safe and effective treatments for most people’s depression, though a great number of people neither seek nor receive treatment. And that unfortunate fact costs all of us enormously, both in dollars and unnecessary pain, suffering and lives.
The cold, hard facts are these: Depression — according to a recent Journal of Clinical Psychiatry estimate — costs the U.S. economy $43.7 billion a year in healthcare expenditure and lost productivity. That would put the cost of depression in Canada somewhere between $4 billion and $5 billion a year — and the cost to the North American economy at close to $50 billion a year.
Yet that doesn’t come close to covering the true costs of depression, as the Journal compilers know only too well. Such figures greatly underestimate the true costs because they’re based on employment data, and a huge cohort of older people simply aren’t formally employed any longer; thus, their contributions — often essential contributions — aren’t taken into account.
Writing in the summer ’97 issue of The Decade of the Brain, a publication of the U.S.-based National Alliance For the Mentally Ill, Dr. Martha L. Bruce points out that, “Not only do most healthy older adults care for themselves and their own homes, they also provide child care, prepare meals, tend gardens, tutor children, shop for groceries, and in numerous other ways help their family, friends and neighbours. Older adults play a particularly important role in their communities by sustained volunteerism to religious, human service, cultural, science and education organizations. The economic value of these contributions and the loss from depression has never been measured.”
Bruce, an associate professor in psychiatry at Cornell University Medical College, adds that there are further costs — “equally elusive in terms of measurement, but also essential to the total equation” — generated by family members who act as caregivers to people with late-life depression. “Just as the patient’s depression results in lost productivity, providing help to the depressed patient takes time from employment, childcare, volunteer services, and other productive activities of the family member.”
And all that, of course, doesn’t come close to putting a price on the immeasurable toll in grief and suffering and shortened lives that depression exacts. Also writing in The Decade of the Brain, Dr. Barry D. Lebowitz, chief of the Mental Disorders of the Aging Research Branch of the [U.S.-based] National Institute of Mental Health, notes that death by suicide “is a significant risk for older people with unrecognized or inappropriately treated depression.”
Studies done in the States from 1980 to 1992 show a nine per cent increase in suicides among people 65 and older, with even sharper rises in older seniors: Among those aged 80 to 84, there was a shocking 35 per cent hike in suicides, and amongst the “oldest old” men, the suicide rate was fully six times that of the general population. All but a handful of older people who commit suicide are suffering from depression, Lebowitz notes, and most of them visit their primary-care physician in the month before killing themselves — nearly 40 per cent see their doctor sometime in the week before they commit suicide, “Yet their depressions are rarely recognized and hardly ever treated.”
Many of those lives could doubtless have been saved if only depression were more widely recognized, de-stigmatized and properly diagnosed. In fact, the majority — as many as nine out of 10 — of elderly men and women with depression do not get treatment for depression, according to Dr. Bruce, for a number of reasons.
“Depression is common in the elderly,” says Ottawa geriatrician Dr. William Dalziel, “and it’s commonly missed by the elderly themselves, because they may assume they’re slowing down or losing interest or not as active simply from the aging process, so the first problem is under-recognition by the elderly. Or denial. Because they grew up in an era in which, if you were depressed, it was a moral failure, they may spend a long time denying they could be depressed and not seek help.” Indeed, says Dr. Bruce: “Lack of professional recognition in part reflects the greater reluctance of older age groups to report symptoms reflecting mental or emotional states. Reluctance to discuss depressive symptoms can reflect feelings of stigma about psychiatry or an abiding belief that one should deal with one’s own mental and emotional problems.”
Depression is also misinterpreted because many of its symptoms mimic those of other conditions. And while the symptoms of depression in an older person can appear much like those in a younger, middle-aged person, they can also present atypically, Dalziel says, “which is why it’s often missed. The first part of the atypicality is the lack of dysphoria — sadness, depressed mood — and in that way the depression can be somewhat misleading. A significant number of elderly people have all the other symptoms but don’t have the depressed mood.
“Again, whether that’s a cohort effect — that they grew up in a time when, particularly for men, you weren’t supposed to be in touch with any emotion — or whether it’s a different biochemical change in the brain, no one really knows. The cardinal symptoms I tend to see [in the depressed elderly] are things like lack of energy, feelings of weakness and loss of interest in things they used to enjoy.”
On top of that, says Vern Gunckel, director of programs for The Canadian Centre For Bereavement Education and Grief Counselling in Toronto, seniors are sometimes mis-diagnosed with depression when what they’re really suffering is grief or loneliness or sadness at not having companionship.
“Some would say there’s a fine line here, but I wouldn’t call loneliness depression, because loneliness can be fulfilled by presence. Depression can’t be fulfilled by presence, because there are other issues. But, for many seniors who sit alone in a room because children don’t visit or someone doesn’t come by or whatever — it’s loneliness.”
Some people who are grieving do need at least temporary support, including antidepressant medication, says Pam Fitzgerald, director of Counselling Services for the Centre, because their grief does more than merely mimic the symptoms of depression. “Some of the signs and symptoms, physically and emotionally and mentally, are the same with depression as with the depression of bereavement, including loss of sleep or sleeping too much, changes in appetite — that sort of thing. Some people — especially widows — lose an extraordinary amount of weight, to the point it becomes dangerous, and they need to have good medical support to get them back up.”
The really important thing, as far as Dalziel’s concerned, is that depression is under-recognized and under-treated. People assume it’s part of normal aging, or that there’s nothing that can be done about it, but that’s simply not so, Dalziel says. “The success rate of treating depression is just as good in the elderly as in the young. Eighty to 85 per cent will respond to treatment in both age groups, so the good news is that people do respond; they can be treated successfully. The bad news is that not enough elderly are getting to the point of treatment.”
The tragedy there is that early diagnosis and appropriate treatment can often nip incipient depression in the bud, prevent a mild case from turning into severe depression, or help bring an already severe depressive episode under control. “Like diabetes, arthritis and other common conditions,” says Dr. Lebowitz in The Decade of the Brain, “depression is chronic and recurring, and it requires long-term treatment accompanied by lifestyle changes and, commonly, environmental manipulations… Older persons with a history of recurrent depression may need to be treated indefinitely to remain well.”
The key point is there’s a wide variety of treatments available, including an array of new drugs that are safe and effective and a number of psychosocial interventions. Some people don’t need drugs — they improve after just a short course of psychotherapy. In fact, studies comparing short-term psychotherapy to antidepressant medications have shown that psychotherapy is as effective as drugs in mild to moderate depression (though a combination of the two — medication and psychotherapy in tandem — works best in most cases).
Psychotherapy’s not for everyone, says Dr. Martin Katzman, senior resident in the Mood Disorder Clinic at the Clark Institute in Toronto. “It depends on the patient,” he says. Psychotherapy alone is “very challenging. It’s hard work, and you have to be the right kind of person to do it. Then it can be extremely effective.”
Often, though, medication is the best medicine, particularly in severe depression. “In the elderly,” Katzman says, “one may attribute their depression to their illness — their sadness to the symptoms — but it may be they simply have a depression. Treat it and then see how they feel. You’d be surprised how a patient comes in and says, ‘I’m so depressed. My osteoarthritis is driving me crazy, and I can’t walk and my leg is miserable.’ Then you start them on an [antidepressant medication]. Suddenly they’re sleeping, they’re eating, their mood picks up and they say, ‘You know what? My legs really hurt, but I’m going out lawn bowling’.”
Take away their depression, in other words, Katzman says, and the patient merely has one illness to deal with; leave the depression untreated, and they have two.
The range of treatments available for depression doesn’t stop with drugs and medications, of course. Ideally, a treatment approach will be holistic, involving as many elements as possible. Social support is critical, including friends, family and other caregivers, plus support groups, perhaps community or church groups, and any other activities — exercise, meditation, breathing or body awareness classes, for example — that actively involve the person with depression.
Dr. Martha Donnelly, Mount Pleasant Legion Professor of Community Geriatrics for the Department of Family Practice at the University of British Columbia, is involved in sports medicine and is doing research on exercise. “Certainly if there was one health promotion technique I’d suggest for anybody with an illness,” she says, “it’s exercise. Get out and move your body and do things. It helps you feel and keep feeling better.”
With depressed patients, Donnelly says, “once we’ve gotten them over the hump and the drugs are working, and we’re trying to reconnect them with their social world, I say, “Use this as an opportunity to get better. Do something for yourself. Improve your health over this.”
That doesn’t work with everybody, Donnelly says, “because I do have patients who don’t do well, but some actually get through the experience of depression and improve themselves, which is very rewarding from my point of view.” Those patients, in other words, learn certain things about themselves by going through a depressive episode that they might not have learned any other way. Because of the crisis, Donnelly says, “they actually fix themselves up, and if the crisis hadn’t happened, they might not have.”