Expert Insights on Treating Depression

Ever been depressed and felt you should be able to recover without help or, worse, that you were born to suffer? Depression in women is a serious issue that too often goes untreated, says psychiatrist Peter D. Kramer, M.D. In this exclusive Lifescript interview, the author of Listening to Prozac discusses how depression treatments have evolved, some surprising causes and what patients need to know about getting help…

About 12 million women in the U.S. struggle with clinical depression. That’s twice as many as men, in part due to hormonal issues, according to the educational group Mental Health America.

Yet many don’t get the help they need, says Peter D. Kramer, M.D., one of the nation’s most knowledgeable experts on treating depression. A practicing psychiatrist and clinical professor at Brown University Medical School, Kramer has written a half-dozen books and hosted the public radio program “The Infinite Mind.”

His 1993 best-seller Listening to Prozac (Viking), confronted the fear and stigma surrounding antidepressant medications. And in his 2005 follow-up, Against Depression (Viking), he argued that depression should be viewed as a serious, debilitating disease, not a “romanticized” state of melancholy.

In an exclusive Lifescript interview, Kramer discusses the most effective depression treatments, the dangers of not treating depression, and why some people are still reluctant to get help.

Based on your own patients, do you think clinical depression in women has increased or decreased in the past couple of decades? And if so, why?
It’s been prominent throughout history. Read older novels and it looks like depression has been part of society forever.

My sense is it’s probably been steady [over time], and the latest research tends to agree with that.

What is depression exactly?
The current definition involves symptoms like low mood, difficulty experiencing pleasure, loss of energy, problems with sleep and appetite, sometimes suicidal thoughts – and having these symptoms solidly for at least a couple of weeks.

[But in more general terms,] depression is these very distressing, paralyzing feelings that interfere with ordinary activities – working, taking care of children, going to school.

So it goes beyond simply feeling blue?
Yes, there are people who are just very blue, and may be, for years running. But depression is distinctive; it’s different from other states you may have been in.

That said, people often don’t recognize they have depression.

Why is that?
Because when they’re in [a depressive episode], people feel they’re worthless, have done everything wrong, deserve to suffer and so on.

People often have so many explanations for it that they don’t think to call it depression.

Can depression happen at any time to anyone or must you have a strong tendency for it?
Lifelong, recurrent depression typically begins in the teens or early 20s. But it can begin any time in life.

Typically, depression is a problem with genetics, often combined with early depravation (such as sexual abuse or violence), then stress and loss later in life.

But all sorts of conditions can lead to a depressive episode – even in people who aren’t genetically predisposed – such as a series of bad events, physical illnesses (including stroke) or hormonal issues.

Is it physically unhealthy to be depressed?
It is. If you look at people with depression at any age, they’re more likely to die in a 10-year period than people without it. And most of the deaths aren’t suicide.

Especially as you get [older, deaths] tend to be from heart disease and stroke, because depression disorganizes the brain and disrupts cardiovascular system functioning. People with depression also do less well with illnesses, such as cancer and diabetes.

Depression in women is also associated with less calcium in the bones. And the part of the brain that deals with memory tends to be smaller in women with chronic, recurrent depression.

So it seems pretty critical to end [depressive] episodes.

When a woman comes to you for depression treatment, what are you looking for?
First [is to make a] diagnosis. And then you want to find any unusual causes – thyroid disease or anemia, for instance, which can cause depression-like symptoms.

And you’re looking for any social issues that someone may need help with, such as an abusive marriage.

You want to be sure you’re not missing obvious causes that could be remedied. Then you want to end the depression episode really quickly.

What’s your typical procedure for treating depression?
It depends on the person.

First, I make sure the person is safe. Then, I like to make sure there’s a plan for movement in career and social relations.

If it’s not urgent, and suicide isn’t an issue, we may talk and try psychotherapy for a few sessions. I like to see some [improvement in] the desperate thoughts.

If that doesn’t seem to be working, or if it’s working slowly, we often add medication. We’ve had a half-century of experience now with antidepressants, and they’re effective.

Will you have to try different medications or combinations?
Yes, you have to find what works.

After the first episode, depression comes back, but with much less severity if you get rid of the symptoms of the early episode – eating and sleeping better and so forth.

How important is therapy in treating depression?
Depression can respond to psychotherapy alone. But the best standard treatment is a combination of medication and psychotherapy.

Medication seems to be extremely good with preventing future episodes. Generally, doctors will prescribe antidepressants for 6-9 months. But it may be longer, particularly if [a patient has] had many episodes.

You’ve written that most depressed people don’t get treated, and many others aren’t treated effectively. Why?
Part of the problem is the illness – people assume there’s something defective in themselves and don’t rush for depression treatments.

There [also] aren’t that many mental-health specialists in some U.S. communities. Also, the health insurance for mental illness isn’t as good as for physical illness. So we have care given by primary care doctors or gynecologists.

A typical patient may be given a prescription and may not fill it. And follow-up appointments may be months down the road.

We used to say about half the people who need help come for treatment, and half of those are treated, and half of those are treated well – so it comes down to 1 in 8. It’s a little better now.

But the data is worse for minorities. African-Americans [tend not to] get treatments for depression.

Is one problem that people don’t want to admit they go to a psychotherapist?
Partly it’s that stigma, and partly it’s availability of treatment, expense and convenience – you don’t want to take time off from work, for example – and just a belief that things can get better [on their own].

But insurance companies bear part of the blame. They don’t make it easy for people to see a therapist long enough.

As a society, are we overmedicated?
We’re clearly not treating depression with medicine or therapy as much as we should be. Every year about 10% of Americans get on an antidepressant, but for a good percentage of those people we don’t know their diagnosis – some may be using antidepressants for smoking cessation, for example.

We need to do a better job of record-keeping and properly training doctors in treating depression.

How did the introduction of Prozac in 1987 change the face of mental illness?
It was like the popularization of psychoanalysis – it took some of the stigma away from saying you had [a problem] and were seeking treatment. And unlike with older antidepressants, people didn’t feel “medicated.”

The other effect of Prozac – and the research tends to support this lately – is it can affect personality – people get less socially anxious and more assertive. It wasn’t just that people were no longer suicidal – a goal of the earlier drugs – but you saw complete recoveries, where people felt more confident. As a consequence, the [expectations] for improvement went up.

Are we getting to a place where everyone will want a “happy pill”?
The medication side effects are very real, so I’m not sure we’re seeing a lot of “cosmetic pharmacology” – though frequent commercials may be increasing interest in antidepressants.

Typical side effects include loss of sexual interest and orgasms. People can be sleepy or unable to sleep, lose or gain weight. And there are a number of less-frequent side effects that can affect almost every organ in the body. These are some serious medicines.

What mistakes do people make with antidepressants?
Not going for help and not considering medication [in the first place].

People often come to me and say, “What about exercise (which boosts serotonin and endorphins)? What about fish oil (to increase omega-3s) or the mood-enhancing herbal supplement St. John’s Wort as alternative depression treatments?”

The critical issue is to end the depression episode. If those alternative remedies are working, fine. But if they’re not working, think about medicine.

Discuss it with your doctor. Talk about side effects. And if you go on an antidepressant be in touch with your doctor frequently – I see my patients every week.

You also have to give the medicine some weeks to work, and not expect immediate improvement.

Are newer medications being developed that show promise in treating depression?
Laboratories are looking at entirely different targets in the brain. There have been some promising ideas, but they’ve turned out to have side effects people can’t tolerate.

And doctors have developed more experience in combining medications, when a single medicine doesn’t work.

Have your views on depression changed since you wrote Listening to Prozac?
Yes – the evidence for the harm depression causes has become much greater. Even though we’re doing more medicating, the concern has shifted to undermedicating, because depression is so harmful over a lifetime.