In a recent article, the eminent doctor and author Sherwin Nuland writes about the deficiencies of modern medicine in which the doctor treats the disease but not the patient who is suffering from the illness. Being ill is a lonely and scary condition and, of all illnesses, depression must surely be one of the loneliest and scariest. A good doctor should be a source of comfort to you in your illness and in the recovery process. You would do well to invest the time and energy in finding a doctor who is not only technically competent but is also able to play this critical role.
Choosing a Doctor
I can’t emphasize enough how important is the choice of a doctor. I am often astonished by how some highly discriminating people, who are careful in the selection of their barber or hairdresser and will go to great lengths to buy the right car at the right price, will take pot luck with whatever doctor is in their neighbourhood. I always like to go to doctors recommended to me by other doctors, figuring that if you’re in the trade yourself, you know the wheat from the chaff.
Credentials are of some value in choosing a good doctor, but sometimes doctors trained at the best places can also be conceited and closed to new ideas. In seeking a doctor, find someone who is clever, up-to-date, sympathetic, open-minded and not too impressed with his or her own opinions. Find someone who will take the time to listen to you and really hear what you are saying. Finally, keep an eye on your doctor. Even the best doctors are only human, can make mistakes and don’t always think of all the possibilities. Even if you are in treatment with a good doctor, you still have some responsibility to use your wits to be sure that you get the best possible care.
Extricating Yourself from an Unsuitable Doctor
A good doctor should not only keep up with the literature but also be open to learning new things. Ignorance is human and often forgivable; it is, after all, a treatable condition. Closed-mindedness, however, is hard to treat and if your doctor is not open to new information, that is a real problem since medicine is constantly changing and new diagnostic and treatment approaches are regularly being developed. It can also be very distressing to end up with a doctor who, rightly or wrongly, reflexively dismisses your point of view, as illustrated by the following cautionary tale.
Many psychopharmacologists suggest that Prozac (or any other antidepressant) be continued for three or four months after a single initial episode of depression has been alleviated. A smaller number of expert psychopharmacologists believe that the medicine should be continued as long as six to eight months.
In the case of recurrent unipolar depression, Prozac should be continued indefinitely to prevent future depressive episodes, if episodes occur yearly.
Similarly, patients who have suffered from bipolar manic depression (lithium treated) must be continued on Prozac for longer periods of time. In these instances, Prozac plus lithium may be used in the acute depressive phase, in the subsequent continuation phase for several months, and finally in the maintenance or prophylactic phase, often for years or a lifetime, to prevent future depressions from breaking through, if lithium alone does not prevent future depressions as well as future manic episodes.
The modern theory of depression hypothesizes that mood disorders are caused by imbalance in the number of small amino acid molecules, called neurotransmitters, that travel between nerves across the so-called synapses in the brain. Synapses are the spaces between two successive nerve fibers.
According to this theory, known as the biogenic amine hypothesis, the three major neurotransmitters located in brain synapses are: norepinephrine (NE), serotonin (SE), and dopamine (DA). The regulating mechanism is a complex one. It includes a process called uptake, whereby some of the neurotransmitter molecules in the synapse are absorbed back into the original nerve endings, where they either degenerate or are repackaged and sent back out again. Sometimes, as a result of genetic and environmental factors, this process produces imbalances in the amount of neurotransmitters in the synapses. An excess of one or more of the neurotransmitters is thought to lead to mania. A deficiency is thought to result in depression.
Most of the scientific investigations of Prozac have focused on depression, with the result that Prozac has received FDA approval for use in major depression. It has not been approved for anxiety disorders because enough data haven’t been accumulated from scientifically conducted trials. Furthermore, from the data so far, the trend may not support using Prozac for primary anxiety disorders.
Nevertheless, when patients suffering from major depression and the milder form dysthymia are treated with Prozac, symptoms of anxiety typically lift along with the other symptoms of depression. To date, a limited number of studies indicate that
Prozac does not seem to be useful for General Anxiety Disorder (GAD) but it is therapeutic for panic attacks and the secondary anxiety seen in major depressive disorders and dysthymia. Once the depression is relieved, the secondary disorder tends to disappear as well.
Masked depression refers to depression that is hidden behind physical complaints for which no organic cause can be found. The physician’s tendency is usually to dismiss these patients as hypochondriacs or to label them as anxious and prescribe minor tranquilizers to calm them down or stimulants to pep them up and get them out of the office as quickly as possible. Masked depression (also known as depressive equivalent, latent depression, hidden depression, overlooked depression, or disguised depression) is potentially one of the most frustrating and therefore serious of mental disorders for the patient, since if not diagnosed correctly and treated properly, the patient is likely to “doctor hop” for years, trying the patience of one physician after another. As Freud himself noted, physical complaints can dominate the clinical picture and lead one to believe that the disorder is strictly physical rather than emotional. In these instances, a succession of M.D.s may never address the patient’s despair. In the worst case, the patient will give up and commit suicide.
Since the underlying illness is depression, Prozac, like other antidepressants, can often be used effectively, although little research has been done on Prozac’s effect on masked depression per se. Because the new antidepressants (of which Prozac, Zoloft, Paxil, and Effexor are examples) have fewer side effects, it is most likely that patients with masked depression will be responsive to these drugs as they have been to the older antidepressants. The critical issue is to make the correct diagnosis of depression, since it is hidden to the patient and often the doctor fails to detect it as well and attempts to treat it as a medical condition.
About 3% to 4% of the population experiences major depression. Manic depression occurs in another 1% or 2%, and another 5% of the population suffers from one of the other forms of depression, including dysthymia, chronic treatment-resistant depression, and depression secondary to medical or other psychiatric disorders. All told, about 10% of the population is afflicted by depression in one form or another, with women about two to five times more likely than men to be affected. Manic depression, however, afflicts men and women equally.
In a usual depression, most people tend to lose weight and have difficulty sleeping, whereas the distinctive feature of atypical depression is that patients tend to gain weight and to sleep more than is normal. They also tend to be extremely anxious, histrionic, sensitive to rejection, and strongly reactive to environmental factors. Major depression typically does not have these latter symptoms.
The symptoms of atypical depression have traditionally responded best to Monoamine Oxidase Inhibitors, but studies now suggest that Prozac and probably other SSRIs may also be effective in treating this disorder.
The difference is basically one of degree. The DSM-IV defines hypomania as “a distinct period of
sustained elevated, expansive, or irritable mood, lasting throughout four days.” Mania is a longer, more intense version of the same thing. The manic mood is not just elevated but “abnormally and persistently elevated,” and it lasts at least one week—twice as long as a hypomanic episode.
In addition, a person in a manic or hypomanic state would be expected to have at least three of the following symptoms:
o excessive self-esteem or grandiosity
o reduced need for sleep
o excessive talkativeness, telephoning, spending
o extremely rapid flight of thoughts along with the feeling that the mind is racing
o inability to concentrate, easily distracted
o increase in social or work-oriented activities, often with a sixty- to eighty-hour work week
o poor judgment, as indicated by misguided business decisions, sprees of uncontrolled spending, or an increase in sexual indiscretions.
Again, the difference between mania and hypomania is one of degree. While both states might be described using terms such as those listed, hypomania can simply seem like a more productive, active period, whereas a full-blown manic attack seriously impairs functioning and often requires hospitalization. Manic people are out of control: they can hurt themselves and others. But those who are hypomanic can also exercise poor judgment. Some patients make excursions from a pleasurable (or sometimes irritable) hypomania to a shockingly destructive mania, affecting everyone and everything around them.