00 depaulo fmt 12/17/01 1:55 PM Page i Understanding Depression (cid:1) WhatWe Know and WhatYou Can Do About It J. Raymond DePaulo, Jr. M.D. Leslie Alan Horvitz John Wiley & Sons, Inc. fcopyebk.qxd 1/11/02 11:51 AM Page ii I dedicate this book to my wife, Joanne Althoff, to my mother, Mrs. Catherine DePaulo, and to my daughters, Mrs. Marianne Plant and Mrs. Margaret Kottke. Copyright © 2002 by J. Raymond DePaulo. All rights reserved Published by John Wiley & Sons, Inc., New York No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopy- ing, recording, scanning, or otherwise, except as permitted under Section 107 or 108 of the 1976 United States Copyright Act, without either the prior written permission of the Publisher, or authorization through payment of the appropriate per-copy fee to the Copyright Clearance Center, 222 Rosewood Drive, Danvers, MA 01923, (978) 750-8400, fax (978) 750-4744. Requests to the Publisher for permission should be addressed to the Permissions Department, John Wiley & Sons, Inc., 605 Third Avenue, New York, NY 10158-0012, (212) 850-6011, fax (212) 850-6008, email: [email protected]. This publication is designed to provide accurate and authoritative information in regard to the subject matter covered. It is sold with the understanding that the publisher is not engaged in rendering professional services. If professional advice or other expert assistance is required, the services of a competent professional person should be sought. This title is also available in print as ISBN 0-471-3955-20 Some content that may appear in the print version of this book may not be available in this electronic version. For more information about Wiley products, visit our web site at www.Wiley.com 00 depaulo fmt 12/17/01 1:55 PM Page iii Contents Acknowledgments v Foreword vii Introduction 1 Part One:Understanding Depression 1 The Experience of Depression 9 2 The Experience of Mania: Bipolar Disorder 24 3 Who Is at Risk for Depression? 36 4 Recognizing Depression in All Its Forms and Guises 46 5 Stressful Events: When People Get Depressed 64 Part Two:Unraveling the Secrets 6 What Do We Know About the Brain? 74 7 Genes and Depression: The Fateful Inheritance 88 8 Hormones, Headaches, and Heart Attacks 95 Part Three:Depression and Mania and Destructive Effects on the Whole Person 9 Depression, Manic Depression, and Relationships 106 10 Destructive Behavior 120 11 Facing up to Suicide 132 00 depaulo fmt 12/17/01 1:55 PM Page iv iv CONTENTS Part Four: Treatments for Depression 12 Getting Help for Depression 157 13 Making the Diagnosis Is the First Treatment 164 14 Medical Treatment 173 15 The Different Kinds of Drugs 182 16 Psychotherapy: Treating the Person 196 17 ECT, Light, and Other Medical Treatments 209 18 Alternative Treatments 220 19 Hospitalization: A Guide for Patients and Families 229 20 Getting Back to Normal 236 21 Going Forward 251 Appendix A: Insurance 262 Appendix B: Helpful Organizations 266 Appendix C: Helpful Books 273 Glossary 277 Bibliography 284 Index 289 00 depaulo fmt 12/17/01 1:55 PM Page v Acknowledgments I would like to thank several people who made this book possible and made it better than it would have been otherwise. First I want to thank Ms. Jane Nevins, editor in chief of the Dana Press for providing the editorial guidance for this project; and William Safire, Chairman of the Dana Foundation and the Dana Press for giving me this wonder- ful opportunity for a second book on depression. Working with patients who are ill with depression or manic depression is one of the most rewarding jobs in medicine. With the possible exception of delivering a baby, there is no professional experience more satisfying than seeing a patient emerging from an episode of severe depression. I happily work every day for this. And since it is in one sense all I do, it is also the only topic today that I could write a book about. I also thank Mr. Tom Miller and Ms. Lia Pelosi at John Wiley & Sons for their editorial work. I also want to thank Mr. Les Horvitz, who has helped me immea- surably to make a message into a book. We met for nearly three hun- dred hours and worked on our own much longer than that to produce this manuscript. Les was an active, engaged collaborator, reading the hundreds of source papers I selected; going over them with me to prepare for a chapter and accepting my interpretation of them (for better or for worse). Les came from New York to Baltimore regularly to discuss with me the book and all its extensions. I held stacks of papers in my hand, lead him through one-on-one seminars of two to three hours duration, and then loaded the papers and chap- ters into his satchel and asked him to return with the draft. His patience and sage advice were a great help and I am grateful to him. I also wish to thank at the top of this acknowledgment Ms. AnneE. Phillips, who will be entering medical school this fall. Anne came to work with me as a research assistant shortly after getting her master’s degree in biomedical technology. She came at a time when I had been doing much more editing than writing. Her talent and my weak- nesses as an essayist created her major work, namely, helping to get me back to writing again. It involved her reading new papers and vv 00 depaulo fmt 12/17/01 1:55 PM Page vi vi ACKNOWLEDGMENTS picking ones I should read. She edited out the duplications and basic flaws in my writing, developed a bibliography, and helped access expert advice as needed. She became a one-woman Kiretsu. Without Anne there would be no Understanding Depression.Thank you. I owe particular thanks to my chairman Paul McHugh M.D., for being a wonderful mentor and strong supporter for twenty-six years and to Kay Jamison Ph.D., for her encouragement and enough ideas for three books as well as a foreword for this one. I take courage from both their work as teachers of students and advocates for patients and families. I thank Barbara Schweizer R.N., B.S., for her support and unflagging friendship; and I thank Dr. Virginia Willour Ph.D. and Ms. Jennifer Coughlin for reviewing the manuscript and giving help- ful advice. I also want to acknowledge my colleagues who have helped me develop ideas included in this book: Michael Kaminsky M.D., John Lipsey M.D., Karen Swartz M.D., Melvin McInnis M.D., Sylvia Simpson MPH, M.D., Dean MacKinnon, M.D., Todd Cox M.D., James A. Potash M.D., and Frank Mondimore M.D.. I want to thank the many dedicated staff members on Meyer 4 including Trish Caruana LCSW-C, Sharon Walsh Esterbrook C.O.T., Rachel Tajenstein, M.S.W. and the nursing staff especially Chris Boyle RN and Deborah Brown RN. I also want to thank the members and staff at DRADA (Depres- sion and Related Affective Disorders Association) especially, Sallie Mink, RN, Wendy Resnick, RN, Cathy Pollock, Anne Hilgartner, Vicki, Paulette Finck, and the members of the Roland Park and Tim- onium DRADA Family Support Groups for their advice and helpful insights. I also want to acknowledge and thank all of the research assistants who have kept our genetics research going and who have provided countless valuable questions and critiques: Krista Vishio, Jennifer Chellis, Erin Miller, Brandie Craighead, Katie Aman, Gwen Walker, Colleen Clarkin, and Lizza Gonzales. To Jen Coleman, who did so many tasks so that I could get started in this effort, thank you. I acknowledge and thank Mr. Ken Heyman for the medical illus- trations contained in the figures. I wish to acknowledge that about four chapters were derived from the “Grand Rounds” discussions I have presented over the last ten years at Johns Hopkins. To my patients and their families, thank you for encouragement, advice, and for agreeing to see a better future when faced with today’s conspicuously fallible enterprise. Lastly to my wife, Joanne Althoff, who has been patient and encouraging, and critical only when I asked her to be one of my “readers.” I offer heartfelt thanks. 00 depaulo fmt 12/17/01 1:55 PM Page vii Foreword Depression, for those who have it, is a painful and inextricable illness; for those who do not, depression is simply inextricable. Depression and manic-depression (bipolar disorder) are common illnesses in adolescents and adults and not uncommon ones in children. Suicide is one of the leading causes of death for those dealing with depres- sion in virtually all age groups. Yet, where there should be open and informed discussion, there is a terrible silence. Depressive illnesses are highly treatable but most who suffer from them never receive any kind of treatment at all. Of those who do, most receive far less than ideal care. We know a tremendous amount about the symptoms, causes, and treatments of depression, but there remains an indefen- sible gap between what clinicians and scientists know and what the people who are depressed know. This is unfortunate and potentially dangerous. Understanding Depression, written by Dr. J. Raymond DePaulo, Jr., a Professor of Psychiatry at the Johns Hopkins School of Medicine, is an excellent bridge between medical science and the sufferer. It pre- sents in a direct and compelling way the most important things that patients and their families need to know about the symptoms of depression and mania; what depression and mania feel like to those who experience them; and what the best and most effective pharma- cologic and psychotherapeutic treatments are. Dr. DePaulo covers the advantages and disadvantages of different treatment options, as well as medication side effects and how best to manage them. He also deals with the co-occurrence of anxiety, alcohol, and drug use, and other common problems that affect the treatment outcome of depression. Dr. DePaulo’s approach to the clinical management of mood disorders is based on taking a long-term perspective on the ill- nesses, rather than focusing on just the presenting episode of depres- sion. This is critical to providing excellent clinical care, and it is a perspective strongly supported by what we know scientifically and clinically about depressive illnesses. I have been privileged to work and teach with Dr. DePaulo at vviiii 00 depaulo fmt 12/17/01 1:55 PM Page viii viii FOREWORD Johns Hopkins for the past fifteen years. He is, without doubt, one of the best clinicians and clinical teachers I have ever known. His under- standing of depression is deeply grounded in science, and his treat- ment approach is characterized by compassion, pragmatism, subtlety, and an obvious affection and respect for the many thousands of patients he has so effectively treated. None of us has a choice about becoming depressed. We do, how- ever, have a choice about becoming informed about our illnesses. Understanding Depression is the best place to begin the process of becoming informed. Kay Redfield Jamison, Ph.D. Professor of Psychiatry The Johns HopkinsSchool of Medicine 01 depaulo intro 12/17/01 2:04 PM Page 1 INTRODUCTION (cid:1) A Clinician’s View of Depression and Manic Depression: Progress, Ignorance, and a Promise This book presents my experience—as a psychiatrist who has seen in consultation, teaching, research, and treatment settings some 8,000 people—with clinical depression and manic-depressive illness. I’ve also had a chance to meet thousands of other patients and their fam- ilies in a variety of forums around the country including support groups and educational meetings. Since many books have been written about depression you may be wondering for whom this book is written. First, it is for people who think that they may be suffering from depression or manic depres- sion (bipolar disorder) and who want to know more about it. Second, it is for people who have already been diagnosed with depression (or bipolar disorder) and are in treatment, but who want to understand more about it in order to deal with it more successfully. Third, I am writing for people who are concerned about a family member or loved one who may be in treatment or who is not receiv- ing any medical care but probably needs it. Those of you in this cate- gory are very likely looking for advice on how to go about persuading the individual who might be depressed to go for help. On the other hand, you may be in a situation in which you feel shut out of the com- munication loop (as happens too often) between a family member and the doctor. It is very difficult to know what you can do to help (or what you shouldn’t do) when you don’t know how the treatment is actually progressing or what outcome can reasonably be expected. I hope this book will help you to participate more effectively as a patient or as a family member. Some readers may be oriented toward self-help, which is truly important as a part of all treatment plans. Nothing in treatment in my experience is more powerful than the efforts of patients and families who understand what they can do. 1