Depression Rx: Psychotherapy w/wout Anti-Depressant Medicines

     There have been several opposing articles written recently in the medical journals as to whether or not "antidepressants" (i.e. drugs) really help treat depressed patients, as opposed to classical psychotherapy and/or placebo. It seems to me that the anti-articles are tilting at windmills. I will discuss here how to (usually) diagnose depression, and who determines  whether or not  the antidepressant treatment ( psychotherapy, drugs, drugs plus psychotherapy, electric shock treatment) really "helps", and what the direct and surrogate markers are used to reach the conclusion that "this treatment helps depression" (better than placebo does).

     To begin with, depression is usually thought of as an affective disease, in  that an interviewer often feels sad after interviewing a depressed person. Freud likened the affect of depression to that of prolonged melancholia, or grief over the loss of a loved one. Depression normally creates some degree of insomnia while it simultaneously  reduces the patient's interest in or ability to enjoy pleasures of any kind: food, sex, entertainment, etc. It is extreme anhedonia (to paraphrase Woody Allen).

     As a family internist, the most common manifestation I see of depression is irritable bowel syndrome, with random abdominal cramps relieved by urgent diarrhea, often  alternating with constipation, where the stool is usually  covered with mucus. The patient is generally totally unaware of this manifestation of depression, but since our entire peristaltic digestive system, from the posterior oropharynx to the proximal rectum is under autonomic control of the spinal cord efferent motor nerves which are in turn controlled by nerve connections to the brain, the relationship  is obvious. (This was first shown by a French-Canadian surgeon who treated a patient with an accidentally self-inflicted shotgun wound to his stomach, and who could then lift an abdominal skin flap to determine how the stomach and digestion responded to extreme emotions.)   And as I treat such patients their attacks, from globus hystericus on downward slowly improve. I should also mention that depression lowers the body-wide threshold to all pains and discomforts, including headaches, and concomitant  lack of sleep further degrades executive ego functions and increases irritability.

    Now what do we mean by "successfully treat"? From the patient's point of view, we have treated him/her successfully if his/her distressing symptoms are reduced or vanish. I leave it to the extreme Freudians to worry about a "flight to sanity", or that  the patient doesn't realize that the depression is persisting, much as Marxists would insist that any worker who didn't feel exploited was brainwashed. So if the patient feels "better" after initiating anti-depressant therapy, is sleeping better or feels less "down", do we consider the treatment to be successful? The problem is that when medical journal articles are written, it is the treating doctors who decide if the treatment "works", and not the treated patient. And there is also political input: the cities of Berkeley, California and Cambridge, Mass. have both decided that electro-shock therapy is useless, and have passed laws banning this treatment of depression within their city limits. I can tell you from personal observation that in some elderly depressed females, where no drug helps, electro-shock therapy definitely relieves many of their symptoms of depression and enables them to resume  the activities of daily living.

     Part of the problem is that while classically depression is thought of as a reaction to a real or imagined loss, I have found that it most often is related to suppressed anger, and there is no pill that treats anger directly. Since most women have been taught by their families and/or society  to suppress or ignore  their anger and not let it show, more women are depressed than are men. Some of the anger results from women resenting the fact that acting as society wants/expects them to act does not invariably bring happiness.I have found that allowing a depressed female patient to acknowledge her anger and not treat it as an unwanted alien often helps to alleviate their depression. Anger is a normal human emotional reaction dating from infancy, and it delegitimizes the ego to tell the child that she "should not" feel angry. It is therefore truly surprising when some of my female patients insist that they "don't have an angry bone in my body". At the same time, there is little or no social disapproval of men who display their anger. Few if any women would openly state at Leo Durocher the baseball manager famously did that "nice guys finish last".One of the most common examples of depression-inducing anger can be seen in an only daughter who is taking care of her mother in a nursing home and who  also has mixed feelings about her mother.

     I personally agree with a famous physician who stated that a doctor's role is "to cure sometimes and to comfort always". If any interaction, procedure or medicine can relieve the psychically and/or physically painful symptoms of depression, then the patient has been helped by the treatment, even if the case is an "n-of-one". I have several elderly patients in my practice who say that an aspirin tablet at bedtime is a wonderful sleeping pill for them. It would benefit no one if I told them that there is no medical evidence that aspirin has soporofic properties. So in my opinion many of the articles pro and con treatment of many psychiatric ailments are not helpful to the average practitoner or patient, and we should use our experience guided by intelligent reading of the literature. And we should ignore the unsubstantiated statement in the PDR at the end of every set of  warnings that the use of beta-blockers (Inderal, Toprol, etc.) makes depression worse. There is no medical evidence for this, and, in fact, several years ago the New England Journal of Medicine published an article showing that beta blockers did not exacerbate any of the symptoms of depression.