There has been some controversy about whether anti-depressants are really effective. Some studies have shown that they are little better than a placebo. I think these results are explainable by the fact that anti-depressants are given sometimes when there was no reason in the first place to think they were going to work. For purposes of discussion, let me distinguish three kinds of depression:
1. Some people are always depressed. They have a bad self-image (low self-esteem) and tend to underestimate themselves in a variety of ways. They may think they are not as attractive, or competent, or smart, or even just plain good, as other people. They may blame themselves whenever anything goes wrong. Because they don’t think well of themselves, they do not reach out for things they think may be worthwhile, because those things seem to be beyond them. These things can include a good job or a particular member of the opposite sex. When this sort of depression is severe, such a depressed person is likely to fail since he/she starts off doing things–or not doing things– expecting to fail. The cause of this sort of depression is an incorrect perception of himself, or herself, learned when that person was growing up. This kind of depression used to be called a neurotic depression. Treatment has to be directed towards changing these ideas. Drugs will not work.
2. It is common to become depressed, even severely depressed, when someone experiences a loss. Typical losses might include a death in the family, being jilted by a lover, the loss of a valued job, or the development of a serious illness. As everyone knows, some people become so severely depressed when jilted that they kill themselves. This kind of depression is a kind of grief, however exaggerated. Medical practice being what it is nowadays, someone very depressed for such a reason is likely to be put on anti-depressants, especially if the prescribing doctor is unwilling or unable to conduct psychotherapy. However, drugs will not work in this situation except insofar as a placebo works. Often, this sort of depression will respond even without treatment over a period of time. The loss has to be replaced somehow. For instance, if a jilted lover stays home day after day and month after month and mopes, recovery may take up to a year. If that person dates, however, even if he/she doesn’t feel like it, recovery can take only a matter of months, or even less, if someone else comes along. A woman I treated (not a crazy woman) went from being suicidal after a man left her to being in love with someone else the following week. Her situation was extraordinary, but not rare. Psychotherapy is helpful treating this kind of depression.
3. There is a kind of depression that is really a kind of illness. It runs in families, tends to start early in life and remits and relapses over time–and responds well to antidepressants. This kind of depression is marked by the presence of vegetative signs.
Everyone who is depressed for whatever reason is likely to have certain symptoms: feeling sad, irritable, withdrawn, and unable to enjoy those activities which are usually enjoyable. Vegetative signs only occur in people who are suffering this third kind of depression. They are:
1. A very characteristic sleeping disorder. Usually such a person falls asleep readily, unless the depression is very severe, but wakes up in the middle of the night, startled and upset, perhaps panicky, often after a bad dream. If he is able to go back to sleep, he wakes up again too early, unable, finally, to go back to sleep. And this happens night after night, week after week. Also, he wakes up feeling bad. The particular way he feels bad is different from one person to the next. Most people feel sad, but some do not. They feel panicky and agitated and worried. Sometimes they are haunted by mistakes in the past. If the predominant feeling is not sadness, this kind of depression is often dismissed as some kind of anxiety disorder. A so-called atypical depression is marked, on the other hand, by excessive sleep. (usually a kind of withdrawal)
2. There is a diurnal variation of mood, that is, the affected person feels progressively somewhat better during the course of the day. If the depression is not very severe, the evenings are tolerable.
3. There is a loss of appetite, usually to the point of losing weight. Again, atypically, some people gain weight; but this is more likely to appear in a neurotic depression.
4. There is a loss of sexual interest.
There may be a variety of other symptoms, including the excessive use of alcohol, but these vegetative signs are at the heart of determining whether or not someone will respond to anti-depressants. In this sort of depression, the response to anti-depressants is very high. And the depression will not go away without the drugs–unless someone waits, often a year or more, for the depression to go away spontaneously.
The anti-depressants may take some time to work and may have to be used in combination, but that is a story for another time.