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Perhaps the best way to regard the genetic component which predisposes a person to become depressed, generally with the help of his/her environment or a specific set of stress-producing depressive triggers, such as death, bereavement, loss of employment or other major family problem.
Depression affects about 5% of the U.S. population, and has remained steady since 1970, with the exception of women under 45; in this subset of the population, depression rates have doubled in the past three decades. This increase has been offset by reductions in other population subsets, including younger men, older men and older women (Fleischmann, 2000). This increasing prevalence amongst this group suggests that there is a social component to depression which has changed in those women born in the baby boom. While there may be a biochemical origin in those increases, life stresses could also be a contributor. Specifically, during that period more women below age 45 have entered the workforce, and therefore are balancing the multiple stressors of job and childcare.
Typically, chronic depression is triggered by one or two "major" events, which start the cycle (Fleischmann, 2000) of depression, depressive behavior, and continued or deepened depression. Subsequent chronic depression is a devil's circle, which uses the negative stimuli of withdrawing from social contact, poor health and continued worry to maintain or deepen the depression.
Depression: The Scent of a Woman
There are a number of films which feature depressed leading actors. The author has chosen the Scent of a Woman because the character had real-world reasons for contracting depression (blindness) which may not have been present prior to his becoming visually impaired.
Al Pacino played Colonel Frank Slade, who had planned a wild weekend with his reluctant 'caretaker,' Charlie, who was hired for that period to accompany Slade on his trip (imdb, 1992). Slade's depression is initially caused by his going blind, but exacerbated by his withdrawal from society as none of his senses could be used in a way that he could use them before.
The author uses this example because, although it was never stated that way in the movie, Frank Slade was clinically depressed due to external traumatic events. His plan was to kill himself after his "blowout" weekend. Thus, by DSM-IV criteria, Slade was depressed:
He had thoughts of death.
He had withdrawn from society.
He suffered from hyperactivity, and yet could not sleep.
He suffered as well from sensory deprivation -- or the lack of sensory stimuli.
He had feelings of low self-worth which, in the movie.
Charlie offered a mirror to Slade in a way which allowed him to rationally accept that he was in fact a worthy human being, and that he could pursue sensual experiences despite his handicaps. The movie ends on a triumphal note with Charlie convincing Slade that he should live. One is left to wonder whether it would be so simple for Slade; subsequent events in his therapy should include more positive stimuli (going out and dancing with women, for example) and supplemented by additional social contact. It is in Slade's reaching out to someone that he was ultimately saved.
General prognosis for the disorder
There are no single cures for depression. While many patients receive anti-depressants without further therapy, it is important to access the fundamental causes of depression in order to insure that the psychotropic drugs do not cause a counter-reaction in the patient.
There are as many forms of 'talk' therapy for depression as there are depression-changing drugs. The choice of drug therapy must be determined according to the patient's tolerance for the drug, and dosage must be carefully monitored. Prozac, for example, comes in dosages from 5 mg/day to 80 mg/day.
The likelihood of improvement in depression depends on the age, physical health and stress in a person's life, in addition to the chosen therapies.
Age is a major contributor to depression and the success rate of chosen therapies. A metastudy analyzing 36 primary data articles demonstrated that younger patients (who had had more depressive episodes) were less likely to respond to depression therapy than older patients. This study found, for example, that ECT (Electro Convulsive, or "shock" Therapy) was less effective on younger patients (54%) than older patients (67%), with the threshold at 65 years of age (Mitchell, 2005).
Pharmacotherapy seemed to cause remission in fewer people over 60 years of age than younger. These differences can be partially explained by co-morbidities, as mentioned above. Likewise, older patients are likely to suffer from dementia and diseases which can lead to dementia.
Like many studies, this metastudy failed to address the impact of multiple forms of treatment. As we've seen with mild- to medium-severity depression, CBT plus anti-depression drugs appears to work better than anti-depression drugs alone.
Although the evidence for anti-depression drugs is conclusive in many patient cohorts, there is a substantial amount of work to be done to complete the picture of diagnosis and treatment of depression. Of particular interest is to close the loop between patients with circulatory disease and depression: while it has been demonstrated that patients with Congestive Heart Failure, ACS (acute coronary syndrome, which refers to STEMI and non-STEMI myocardial infarctions) and related diseases are more likely to be depressed, it has not been demonstrated that ameliorating depression improves those patients' medical outcomes; in other words, curing depression may not cure the underlying disease, or even halt its progress (Carney, 2007).
Additional questions need to be answered. Why is it that teens appear to be more likely to commit suicide if they take anti-depressive drugs? Is the effect due to the drugs, or a correlate? And what is the reason why women appear to be more susceptible to depression generally, including genetically-linked depression, while men are more likely to become depressed due to environmental factors?
Psychotropic drugs continue to improve the therapeutic outcome for patients. They have paradoxically raised even more questions about the environmental and biochemical causes of depression. As we learn more about them, we should be in a better position to treat the patients in the future.
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