THE DEMON WE CALL DEPRESSION

CHICAGO TRIBUNE MAGAZINE / FEBRUARY 22, 1976

To understand the deep depression that gripped Harold Hickey (not his real name), imagine the worst you've ever felt and multiply that dark mood 100 times. In one three month period, Hickey dragged himself out of bed on only a dozen days--to drive a taxi just enough to pay the rent. Because of his physical inactivity, terrible bedsores broke out on his buttocks and lower back. He became emaciated, barely summoning the energy on some days to swallow a bit of dry cereal.

Last Thanksgiving Eve, life nearly ended for Harold Hickey. Unable to live any longer in such psychic pain, he swallowed 30 Amytol capsules (sleeping pills) and was saved only when his estranged wife telephoned to ask if he planned to visit their children the next day. Hickey, not completely resigned to death, told her what he had done; she called the police, who took him to a hospital.

Six weeks later I saw Hickey on the 13th-floor psychiatric ward of Rush Presbyterian-St. Luke's Medical Center. A slight, gray man of 40, he was remarkably improved as the result of taking Elavil, a potent medicine, and having daily talks with a psychiatrist. He was able to concentrate on reading a book once again and was planning for the future.

Hickey told me that he had a Ph.D. in metallurgy and had worked for several large corporations until 10 years ago, when he was first stricken with depression. Unable to work at his profession, he existed by selling used cars, peddling neckties and driving a cab. He was hospitalized four times. His first wife divorced him, his second simply left.

Occasionally, Hickey's miasma was dispelled and he became manic, feeling 10 feet tall and buying his wife clothing that he could not afford from high fashion boutiques. For himself, he rented expensive cars. But always there followed a downswing--gloom so dark and brutal as to crush him. In Hickey I saw a man whose life had been wrecked by depression.

Hickey's physician since the attempted suicide had been Dr. Jan Fawcett, chief of psychiatry at Rush-Presbyterian. He is an acknowledged authority on depression, having treated more than 1,000 depressed patients and having pioneered biological research that may one day help explain the bodily origins of melancholy..

A briskly cheerful man of 41, Dr. Fawcett becomes angry when he considers how most of society regards depression: "People say. 'Cheer up, count your blessings,' to the depressed person. They regard the illness as a weakness, as self-indulgence. They don't know that depression is the most painful experience there is. I've had patients tell me that it's worse than the pain of cancer. The depression victim suffers double jeopardy: Not only is he in pain but he is disapproved of, by himself and others. If he had cancer, people would sympathize."

Depression, the most common mental illness, usually goes unrecognized and untreated. At any moment, says Fawcett, some 8 million Americans suffer from severe depression and 30 million more, according to surveys, rate their mood as depressed. Their symptoms are varied and insidious:

There are 20,000 reported suicides in America every year, and many more probable suicides are called something else by the authorities (the victims of "accidents," for example, in which an auto runs off the road and hits the only light pole within half a mile). Depresssion figures in many of these.

Depression goes back to the beginning of recorded history. Dr. Nathan S. Kline, in an excellent book on the subject ("From Sad to Glad--Kline on Depression") notes that King Nebbuchadenazzar of Babylon suffered terribly from the disease more than 2,500 years ago. The king was plagued with insomnia and wildly erratic moods.

More recently, depression afflicted Dostoevski, Poe and Hawthorne. Charles Darwin put his work aside for 18 months after his famous fossil-collecting voyage because depression kept him from reading.

Winston Churchill masked his "black dog" of depression by looking fierce. Depression drove Hemingway to suicide. The treatment Sen. Thomas Eagleton (D., Mo.) took for depression cost him the vice presidential nomination in 1972. Astronaut Edwin (Buzz) Aldrin Jr., second man on the moon, was secretly hospitalized for a month because of depression.

Only about 10 percent of depressions are of the true manic-depressive or bipolar variety, like Harold Hickey's, in which there are sharp up and down mood changes. But whatever the type, depression seems to afflict women twice as often as men. (Dr. Fawcett and other psychiatrists believe, however, that uncounted thousands of males "treat" their depressions by drinking to the point of alcoholism.)

Sometimes crises precipitate depressions. A person's spouse dies, a job is lost. But after a period of gloom, the normal thing is for a person to bounce back: to adjust to being alone or to find a new spouse, a new job. Truly depressed persons are the ones who don't bounce back. It is Fawcett's belief that they have been in a depression all along without recognizing it; failing to perceive that hopelessness about life and failure to extract any joy from anything are ominous symptoms.

Percy Knauth, a 57-year old writer and editor for Time-Life, Inc., graphically describes the onset of his depression in a recent book, "A Season in Hell" (Harper & Row, $6.95.).

"My life had turned inside out so that everything I saw was a photographic negative," Knauth writes. "Where I should have felt hope, there was only despair. Where life with its continuing promise should have sustained me, only the oblivion of death attracted me now, for living had become a hell on earth."

Normally, a robust lover of life, Knauth felt as "though some silent, dark force had pulled the plug out of my life and let the vital iuiees drain away until it was an empty shell." Going to a doctor for a checkup, he was asked how he had been.

"I couldn't even begin to find words to tell him. I sat there and stared at him and then I burst into tears.... I wept uncontrollably. I shook, I sobbed, and the sealding tears streamed down my face. I ean remember thinking in honest astonishment: Jesus! What's happening to me now? But I couldn't stop, not for anything or anybody. I didn't even want to stop. For the first time in weeks I felt some release from the agony that had been pursuing me so relentlessly."

Happily. there is relief available for most depressives. The breakthrough came in the 1960s, when it was diseovered that an ancient drug, reserpine (used to treat high blood pressure), produced severe depressions in some patients; another, newer drug being used to combat tuberculosis was found to have the opposite effect: it induced euphoria and even mania.

Backtracking from these discoveries many medical investigators began to believe that depression is caused by a chemical malfunction in the brain. Normally, complex chemicals called catecholamines are released by certain of the brain's 10 billion nerve cells to carry electrical messages to adjoining cells. If something goes wrong with this process, the theory holds, the signals having to do with moods or emotions may: be affected, causing depression.

So, using the antituberculosis drug as a starting point, researchers developed antidepression drugs known as monamine oxidase (MAO) inhibitors. These, taken by a depressed person, increase the supply of catecholamines by slowing down the rate at which they are burned up in the body.

The MAO inhibitors, although widely used, have unwanted side effects. Drugs known as tricyclics (Tofranil, Elavil, Aventyl, etc.) are now preferred for 70 percent of depressive patients by psychiatrists who use drug therapy. Tricyclics, too, make more catecholamines available to the brain cells, but in a different way.

For the manic phase, many physicians now choose lithium, lightest of the solid elements, whose tranquilizing properties also were discovered by accident when an Australian doctor injected some into a guinea pig. About 20 to 30 per cent of depressives are not helped by the first drug tried on them and require other drugs as well as psychotherapy or electric-shock treatments.

Fawcett became interested in what amounts to brain chemistry in l964, when he joined the Depression Research Unit of the National Institute of Mental Health in Bethesda, Md., in his first job as a psychiatrist. There, with Dr. William Bunney Jr., a pioneer in the field, he found that depressed persons could be detected through chemical analysis of their urine. (Apparently the psychological stress that accompanies depression adds certain biochemical properties to bodily wastes.) Continuing his research at Rush-Presbyterian, Faweett is now working with a biochemist, Dr. Hildegarde Hoff, to learn exactly how antidepression drugs affect the brain.

To comprehend the biochemical miracle of these drugs, one must understand how little medical science could do about depression in the past. Early physicians treated depression with hot and cold baths, special diets, opiates, sleep therapy, even whipping with stinging nettles. Later physicians used electric shock for the worst cases, with some success.

The demon's origins: a psychoanalytic view
Traditional psychiatrists--psychoanalysts--try to use a patient's own words, rather than drugs, to give a depressed person insight into the origin of his problems and thus relieve the symptoms of depression.

According to Psychiatrist Nathan S. Kline, the analysts believe depression results from hostility turned inside, that it stems from anger originating in the early parent-child relationship.

"A child somehow fails to recive from the parents the love and support it needs," Kline says. "The child resents this bitterly but cannot express it openly because of guilt and so turns the anger inward.

"The depressive individual is said to be one who is trapped in an early oral stage of development. He has remained dependent on others for emotional support, just as he was once dependent on the mother for food. He is constantly seeking reassurance for his fragile, ill-developed ego, and he lapses into depression when those around him fail to meet this insatiable need. Again the root problem is presumed to be that he is reliving, over and over, the anxiety created when he was denied proper support."

Traditional psychiatry has its own theories about the origins of depression but there are too few psychoanalysts--fewer than 2,000 in the United States--to have much effect on the vast number of depressives. Even if all the psychoanalysts and all the other mental-health specialists did nothing but treat depressives, they could see only a small percentage of those urgently in need of help. But now, with drugs, it is possible for the nation's 140,000 primary-care physicians to treat most depressives--provided that they can be trained to recognize them. It is a sad fact, documented in several surveys, that three-fourths of all persons who kill themselves have consulted a physician a few months or less before their deaths. It is probable that many of these were already exhibiting suicidal symptoms that went undetected.

Increasingly, Dr. Fawcett is moving toward specialization in depressed patients. He sees the worst cases. "Seventy to 80 per cent of depressives could be treated by general practitioners" he says. "Psychiatrists have to be called in for the others, but only half of this group requires hospitalization." And despite his success with chemical therapy, he cautions that the mind-altering drugs should be reserved for cases of severe depression and not used for the ordinary short-term "blues" that everyone experiences.

Fawcett hospitalizes the sickest of his patients for three to 12 weeks. One drawback to treating depressives with tricyclics is that it takes about three weeks for the drugs to begin working, and suicide is a constant risk in certain patients if they are not given "protective detention" in a hospital. "I ask them outright if they intend to kill themselves;" he says. "Those with a specific plan (gun, knife, pills) are the worst risks, especially if their scheme offers no chance for rescue." Some patients argue that they have the right to choose death over their living misery. He doesn't offer counterarguments except to say that their choice should be made in six weeks when they're feeling better.

The change that occurs in profoundly depressed patients when they begin responding to medication is heartening-- often astounding. Fawcett introduced me to a 44 year-old housewife who had been in the hospital for 17 days, taking 100 mg. of Elavil every night. It was her third hospitalization in the two-year course of her depression.

"When I came to the hospital " she said, "I felt this steel band gripping me around the head, crushing it, and I wanted the doctor to order a skull X-ray. I had gotten to the point where I had trouble getting up and getting dressed in the morning. I couldn't prepare dinner for my husband; every night for months we had to eat out in restaurants."

This day, the nurse wrote in her chart that the woman had smiled for the first time since her admission. "I want you to know," the woman told Fawcett, "that the smile was really spontaneous--it was no put-on. I even talked today at the patients' ward meeting."

"But the idea of going back home seems to frighten you," the doctor told the improving patient. "I'd like to see you get out of the hospital for a few hours --go to lunch with your husband." The woman, agreeing, looked thoughtful.

"You know," she said, "everybody kept telling me to lift myself up by my bootstraps and things like that. It was well-meant advice, but it didn't do me any good. Only now for the first time am I starting to beiieve that I can be helped."

Fawcett brought in another woman about 50 and quite thin; her depression had begun when she had to put her 75-year-old mother, who had been her sole companion and housekeeper, into a nursing home. About the same time, the patient's employer--the president of a huge insurance company--announced that he was retiring and she, a secretary, would be assigned to some other executive.

Although a skilled executive secretary with many years of experience, she felt her typing and shorthand skills were not good enough for a new boss. "My hands would shake, and I would make so many errors typing that I'd have to retype a letter five times," she said. "I used to cry all the time. I had so little energy that when I got home I couldn't even make myself a peanut-butter sandwich. I would just go to bed. Saturdays and Sundays I'd stay in bed all day."

Now, with Elavil taking hold, the woman reported she was feeling much better. "I sleep well," she said, "and the other day I read through a newspaper for the first time."

She still thought she could not adequately serve a new boss, but Fawcett was reassuring. "You'll be feeling even better when it's time for you to go back to work," he said. He also suggested that the woman go back to her apartment on a six-hour pass, just to get used to the idea of being on her own again. When she looked uncertain, Faweett added: "A whole new life has been forced on you, and no pill is going to make it palatable. But when you feel better, you'll cope better."

Drugs are not all that a seriously depressed patient requires. "It's not entirely chemical," Faweett said. "You can't separate biochemistry from the emotions; a very depressed person requires some psychotherapy." At the hospital's Marshall Field IV Center, 1720 W. Polk St., he regularly sees depressives as out-patients while they're taking their medicine. Most therapy is short-term but though a few patients have been in treatment for five to seven years. Some will take medications for the rest of their lives.

Left to itself, the average depression persists for six months to two years and then goes away; the patient adjusts to the symptoms and the disease eventually seems to "burn off". But the cost in suffering to the patient and those around him is incalculable. "I hate to think of the cost to society of people in high places, beset with a tremendous hopelessness about life that affects all their judgments, having to make important decisions," Fawcett said.

For Dr. Fawcett, there are not enough hours in the day to wrestle with the dark demon. Leaving his home in Highland Park well before 7 every morning, he uses the time while driving to the medial center to good advantage. Motorists passing him on the Edens Expressway stare curiously at the sandy-haired man in a white convertible who dictates into a tiny tape recorder. What is he saying? Very possibly Jan Fawcett is hammering away at his favorite theme: "Look, diabetes is a disease, and the patient takes insulin to control his blood sugar. Hypertension is a disease, and the paient takes drugs to bring down his blood pressure. Why can't society accept depression as a serious disease, one with biological underpinnings, and one that can be successfully treated with medicine? The important thing is to recognize depression and treat it."