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In the times of Prozac

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Feeling down? No harm seeking help…
Feeling down? No harm seeking help…

We may not have the vocabulary to deal with ‘depression’ but it’s a very real affliction, says psychiatrist and writer DR. VIJAY NAGASWAMI

Many persons with depression end up untreated, languishing in sub-optimal lives…

I have lost count of the number of people who tell me that depression is a “weakness of modern times” and all you need to be is strong, if you want to fight it and get your life back on track. Such people usually vehemently refuse either medication or psychotherapy when it’s patently obvious that they are fairly seriously depressed, saying that they just need a few good breaks in life and some good, old-fashioned will power to become cheerful again. Ah, were life that simple! Even I, a champion of natural healing processes, who doesn’t usually prescribe medication unless compelled to, find myself reaching for my prescription pad more often than I would really care to. For, I know that depression is not just someone going through a hard time and feeling a bit down in the dumps. It is an illness that, in contemporary psychiatric terminology, is referred to as a “Mood Disorder”. And it affects far more of us than we think. In fact, as any good general physician will tell you, almost a third of patients visiting a doctor would warrant a diagnosis of depression.

Strangely enough, most Indian languages do not have a word for “depression”. There are words for sadness, melancholia and so on, but it’s very hard to find a word that means depression. Which is probably why many of us find it hard to say, “I’m depressed”; we don’t have the vocabulary for it. And when we say it in English, it ends up sounding like a Western import or a disease related to “decadent” lifestyles. Undoubtedly, an unhealthy lifestyle does contribute to depression, but there are several other factors that do too. Genes, for instance. Depressive disorders do tend to run in families. Before we go any further, let’s get one thing out of the way. Depression is not just feeling sad. While sadness is one of the symptoms of depression, clinical depression or Major Depressive Disorder is more than just a feeling of sadness. When we lose a loved one or lose our jobs, we tend to feel sad, afraid, angry and bewildered. This is a normal grieving response. And, one would expect that within a few weeks or months, these feelings go away and we tend to stumble on with our lives.

When it persists

However, if we are unable to shake off these feelings even after a passage of time and they are accompanied by other symptoms like those described in the box, then we are probably getting into a state of depression. It’s no longer a question of your mind struggling with a shattering life event. The brain too has become involved. The levels of circulating Serotonin or Noradrenaline or both, in your brain, have gone a bit out of whack.

The brain is a fascinatingly complex organ. Different parts of the brain control different bodily and mental functions. The part of the brain that governs our mood is called the Limbic System. In this system, as in the rest of the brain, brain cells communicate with each other with the aid of chemical messengers, that are called neurotransmitters. Serotonin and Noradrenaline are the principal neurotransmitters that are responsible to ensure the relative stability of our mood, and they need to be circulating in adequate levels to ensure that they are able to do their jobs. When life bowls us a devastating doosra, the levels of Serotonin and Noradrenaline in our brains are reduced and, therefore, we experience a feeling of depression. However, after a few weeks, we cope with our life event and these chemical messengers bounce back to their baseline levels. For some of us though, this bounce back doesn’t happen, and we then go through a clinically significant depression. Sometimes, even a combination of relatively minor stress factors can precipitate a depression. Additionally, there are certain situations when our neurotransmitters can go a bit awry: the post-partum period, during recovery from a major illness like a heart attack or a stroke, during andropause and menopause, and in association with other chronic and/or severe mental and physical disorders.

However, most often, depression happens with none of these predisposing factors to explain its appearance. And this is what most people have a hard time dealing with. They feel they have no reason to feel depressed; that everything’s going just fine; that they should “snap out of it” and not make a “fuss”. Everybody around seems to feel the same way too. As a result, many persons with depression end up untreated, languishing in sub-optimal lives and run the serious risk of not only a variety of physical illnesses that they become vulnerable to, but far worse, a fatal consequence — suicide. Not all depressed persons end up committing suicide, in fact only a relatively small number do, but the possibility of this outcome alone warrants organised intervention. Depression is also part of another illness called Bipolar Disorder (it used to be called Manic-Depressive Psychosis). As the name suggests, sufferers usually experience wild mood swings, ranging from mania (euphoria, extreme irritability, feelings of grandiosity and excessively high energy levels) to depression (feeling sad, apathetic, feelings of low self worth and guilt, and very low energy levels). Lest you conclude upon reading all of this that you too are Bipolar, please do remember that having one or two of these symptoms doesn’t qualify you for the diagnosis; you need to have all of them.

A variety of treatments

Today, medical science has a wide variety of treatments for depression. Top of the list is anti-depressant medication (of the Prozac variety). These drugs basically try and return your neurotransmitter system back to normal by ensuring that both Serotonin and Noradrenaline are available in adequate levels in the brain to do what they are supposed to. Yes, these drugs do have some side effects, as most medicines do, but they are relatively minor and manageable for the most part, regardless of what the Internet says. If you stay in regular contact with your psychiatrist during the treatment process, your side effects can be monitored and with some judicious dose adjustments, most of these can be easily managed. Most of these drugs take a few days to start kicking in, so don’t expect immediate results. And you might have to take them from a few weeks to a couple of years, depending on the nature and severity of your illness. Usually, when your mood remains stable, your brain’s natural mechanisms take over and reset your neurotransmitter levels to what is required to remain “euthymic” (stable mood). Sometimes, particularly when a bipolar depression is in evidence, your psychiatrist may also add what’s called a “mood stabiliser” to your prescription, which, as the name suggests, makes sure that your mood doesn’t swing all over the place. Typically, if you are free of symptoms for about three months, your psychiatrist will consider a phased reduction of your medication dosage and stop it altogether eventually.

Over-prescription

Unfortunately, ever since Prozac appeared in the market, anti-depressants have been frequently over-prescribed. Equally unfortunate is the tendency for many people to self-medicate with these drugs. Believe me, nothing can be more dangerous than this. These drugs need to be administered only under the supervision of a medical practitioner. Also, please do remember that the pills for depression are not like “uppers”, please don’t expect a pill or two to solve all the problems in your life. They can, at best, create a level playing field and give you a platform with which you can deal with the issues in your life.

If, at any point in your life, you find that you’re feeling depressed and you can’t shake the feeling off, just visit a competent psychiatrist and get a quick evaluation. You lose nothing, but you actually stand to gain a better quality of life. Don’t expect your psychiatrist to come highly recommended though. Most people in our country still don’t like talking about their shrinks.

Lookout for…

If you have not experienced any major life event or if it has been at least two months since such a life event took place, and you have several of the following symptoms, you might be suffering from depression and should consider visiting a psychiatrist

Feeling sad or empty most of the day nearly every day for at least two weeks

Markedly diminished interest or pleasure in all or almost all usual activities

Unprovoked crying spells

Extremely low sense of self worth or unprovoked feelings of guilt

Either a significant decrease in appetite and weight despite not dieting, or eating significantly more than normal and weight gain.

Either difficulty in sleeping or waking up at 2 or 3 a.m., or feeling excessively sleepy through the day.

Feeling either very agitated or very lethargic and slow.

Unusual fatigue and loss of energy

Difficulty in concentrating on normal activities.

Recurrent thoughts of death or suicidal ideas.

Above symptoms come in the way of discharging responsibilities at work as well as in personal and social relationships

(Modified from the American Psychiatric Association’s Diagnostic and Statistical Classification of Mental Disorders, 4th edition, Text Revision)

The writer is a Chennai-based psychiatrist and author.


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