Both depression and anxiety are very common. Estimates of the numbers of Americans with clinical depression vary greatly – some as low as 10%, some as high as 20%. Assuming that the actual number is somewhere in between these extremes, it still means that a very large number of people are suffering – between 30 and 60 million at any given time. Anxiety is about as common as depression. The Anxiety Disorders Association of America estimates that the number of Americans, over the age of 18, suffering from anxiety is 18% or about 40 million people. These are huge numbers. Unfortunately, the numbers of people receiving treatment for these illnesses is estimated at only about 20%. This means that there may be as many as 36 million Americans suffering from untreated depression and 32 million suffering from untreated anxiety.
Untrained individuals should not attempt to diagnose themselves or loved ones, but the presence of some of the key features of depression and anxiety do warrant evaluation by a qualified professional. The most common symptoms of depression are first and foremost, a persistent depressed mood, then, loss of interest or pleasure most of the day for most days, significant unexpected weight change, up or down of more than 5% of body weight, over or under sleeping, feelings of restlessness or being slowed down, fatigue or loss of energy, feelings of worthlessness or inappropriate guilt, diminished ability to concentrate or indecisiveness, recurrent thoughts of death, suicidal thoughts or suicidal attempts or specific suicidal plans. The most common symptoms of anxiety are both mental and physical and range from mild to severe – a sense of uneasiness, worry and nervousness at the mild end to a stronger sense of apprehension, fear without apparent reason, fear of going “crazy”, fear of impending danger or death at the more severe end. Physical symptoms can include dizziness, lightheadedness, difficulty with sleep, chest or abdominal pain, nausea, sweating, increased heart rate and diarrhea. Because so many of the symptoms of anxiety are physical and because of the stigma of emotional illnesses, many sufferers consult their physician first and their symptoms are treated simply as physical disorders.
Neither depression nor anxiety refers to a single illness. Both are best understood as a group of illnesses with some common features. The DSM IV (Diagnostic and Statistical Manual of the American Psychiatric Association) lists 10 different diagnoses of depression and 11 different diagnoses of anxiety (with four others that are not actual diagnoses). Furthermore, an individual diagnosed with either depression or anxiety, very likely also has some symptoms of the other illness as well as the primary diagnosis. As can be seen from the description above, both illnesses can share common symptoms of restlessness, difficulty with sleep, difficulty concentrating and thoughts/fears of death. Clearly, these are very complex illnesses that frequently overlap.
With such a complicated clinical picture, what can one expect from treatment for depression and anxiety? First, an initial word about prognosis: these illnesses follow the conventional wisdom for the prognosis of most medical conditions. These include assessing intensity, duration and response to prior treatment. Mild intensity, short duration and positive response to any prior occurrence all indicate a good prognosis. Symptoms that are intense, long standing and have been treatment resistant are all indicative a much more difficult prognosis. A thorough history helps fill-out the assessment of intensity, duration, response to prior treatment, as well as patterns of onset of the illness for the individual.
The inexperienced person (including graduate students in psychology) who reads through the DSM IV will be left with the impression that each of these numbered diagnoses refers to a specific, separate illness. Some day we hope this will be true. Even with a thorough diagnostic assessment, the assignment of a specific DSM IV diagnostic number to the illness is an imprecise science. An analogy is the three outdoor thermometers that I have – one a mercury filled tube, the other two are digital. These two give a numeric reading, including tenths of a degree. The problem is that, when the three are placed side by side, they disagree on the temperature by as much as 1.2 degrees. However, the untrained person looking at one of the digital readings assumes that not only is the temperature correct, it’s correct to one tenth of a degree. This implies a precision that in fact doesn’t exist.
The manufacturer could just as easily produce a thermometer that gives readings of hundredths or even thousandths of a degree – 97.482 degrees. Who know what the actual temperature is – somewhere around 97 degrees. Or in the words of my Australian friends, “stinkin’ hot!” For most of us, this is precise enough. Unfortunately, with mental illnesses, we simply are not nearly as precise as we would like to be and need to be.
The DSM IV tacitly acknowledges this problem as both depression and anxiety have among their listed diagnoses: Depressive Disorder Not Otherwise Specified and Anxiety Disorder Not Otherwise Specified. These are a “catch-all” number for a person who is clearly either depressed or anxious but doesn’t quite fit the criteria for one of the other nine or ten diagnoses. Most people present with a picture that is “most like” one the specific diagnoses, but often with some overlap with other diagnoses. Most clinicians think of the DSM as a useful start, but then enrich the understanding of the person by reconstructing their life history. This provides an important context for the illness in a particular human beings life. Since the DSM was revised, it seeks to describe illnesses without reference to theory – looking only at the presenting symptom pattern. The purpose of this approach was to make research much easier and provide a tool that would be useful for researchers as well as clinicians.
An old Chinese proverb says, “May you live in interesting times”. In the field of psychology, we certainly live in interesting times. A little over hundred years ago (1893), Freud published Studies in Hysteria and psychoanalysis was born. Academic psychology began a bit earlier with opening of a research laboratory by Wilhelm Wundt in 1879 at the University of Leipzig in Germany. These two disciplines lived in two different worlds and there was very little contact between them. Psychoanalysis was focused on discoveries that would be clinically useful. Research psychology was focused on gaining basic information on how the nervous system and the brain worked.
Ironically, Freud worked as a neurologist (performing experiments on simple nervous systems of animals) before he became interested in hysteria and clinical psychology. With the publication in 1895 of Project For A Scientific Psychology, he hoped for an eventual integration of the two disciplines.
We are a long way from that goal. Yet a great deal of clinical and theoretical progress has been made. Efforts from both sides have been made to find common ground and to see to what extent each field can support and inform the other. Neuropsychoanalysis and developmental psychoanalysis represent important and valuable scientific work (and disciplines that didn’t exist 40 years ago) that uses psychoanalytic concepts to explore critical brain activities using functional MRI. Not only has much of this work supported clinical psychoanalytic concepts, it has lead to refinements and improvements in psychotherapy. From the neuropsychological side, Joseph LeDoux’s The Synaptic Self: How Our Brains Become Who We Are is a good example of the efforts being made to understand how clinically useful concepts arise out of our biology. He begins with the synapse, the basic connection between nerve cells in the brain, and then shows how a sense of self develops by the ever-increasing complex relationship and organization between groups of neurons. This is progress – just not as fast as anyone would like.
My point is to be clear about what young and undeveloped sciences psychology and psychiatry are. With some illnesses our patients do very well. With others, the illness can be difficult and stubborn to treat and the gains are more modest. Most of the patients that I see do well in treatment and I hear similar results from my colleagues in psychology. But most of these people have mild to moderate depression or anxiety. A recent (June 2008) article in Newsweek recounted the tragic story of Max, a 10-year-old boy who, from the day he came home from the hospital, couldn’t sleep normally and was often in an inconsolable rage. At age two, he had his first psychiatric consultation and diagnosis – Bipolar Disorder, Hyperactivity. By age 10, he had been on 38 different psychiatric medications, but still careened between depression, anger and occasional euphoria. The up-surge of hormones at adolescence will complicate his life and his treatment even more. The diagnosis of Bipolar Disorder in infants and children is quite controversial.
Years ago, Bipolar Disorder was understood as a biologically inherited disease that nearly always emerged in mid to late adolescence and was diagnosed by the clinical picture and a history of the illness in earlier generations in the family. By the 1970’s many of these patients improved dramatically with the medication Lithium Carbonate. Is this the same illness that Max has? Although he has the same mood swings (but with some significant differences), the course of his illness and his very limited response to medication would suggest not. Have the powerful medications on a young and developing nervous system made his illness worse? Is there another treatment that would have been better?
We don’t know. It is humbling yet very important to recognize the limits of our knowledge. Naming doesn’t mean understanding and it is very clear we don’t understand Max’s illness. But we have the comfort of an implied precision when we call it Bipolar Disorder, Hyperactivity. To further illustrate this issue, the DSM IV has a diagnosis of Cyclothymic Disorder. This is a sort of Bipolar Disorder, Lite. The patient has similar mood swings of Bipolar, but the depression isn’t quite as severe. Is this a milder form of Bipolar Disorder or something quite different? We don’t know, but if we did, a treatment regimen might be clearer. In the mean time, we have the comfort of the implied precision of a distinct diagnosis.
As with any illness, treatment for depression and anxiety is determined by the presumptive or working diagnosis. Sometimes this is pretty straightforward. For example, if the illness fits the criteria for an organic depression, then the first choice for treatment is medication. But even with less severe illness often the diagnostic picture is much more complicated and the task is identify all the likely contributors, both organic and psychological, to the depression or anxiety. This is the purpose of a thorough diagnostic history and informs the clinician’s decisions for an initial approach to treatment. These include whether to hospitalize (extremely rare for a person seeking outpatient psychotherapy) refer for medication and if so, to whom. If medication is indicated, do they need to be seen by a psychiatrist or is their internist or family physician satisfactory. Other important decisions must also be made. Frequency, cost, and scheduling of sessions must be agreed upon. But most importantly, from a psychologist’s perspective is to understand this illness from within the patient’s perspective.
Only with a deep understanding of the patient from with in his/her own perspective can the psychologist respond best to the concerns raised by the patient. In spite of the abundance of jokes and cartoons to the contrary, understanding from with in the patient’s perspective is not the same as agreeing with the patient or asking endlessly, “How do you feel about that?” If patient and therapist sit in complete agreement, nothing will ever happen – except both parties will soon become bored. A good psychologist is always interested and curious, seeking to understand apparent inconsistencies, missing information, common areas of life that are avoided, significant experiences and events, etc. There is much to learn in order to accurately identify where, how and when to intervene. Only with a thorough understanding has the psychologist “earned the right” to actively intervene with the patient. Each intervention is then evaluated for its effectiveness and adjustment and refinements are made accordingly.
There is a lot written in the professional literature about EVTs (Empirically Validated Treatment), especially from the academic side. These are treatment protocols (often refinements of Cognitive Behavioral Therapy, also called CBT) that have been demonstrated to work effectively (reduce symptoms) with a particular diagnosis. This sounds like great science and is modeled on the same thing your physician does in medicine. Unfortunately, we are once again enjoying the ersatz comfort of an “implied precision”.
The literature is full of the differences between the research setting and the clinical setting as well as the question of generalization of results (if it works in this context will it work in that one?). In research, patients are selected for only one diagnosis – a luxury that few clinicians find in real life. A second problem is that the measurement of symptom reduction often doesn’t translate into better functioning in every day life. Alan Kazdin, President of the American Psychological Association, a Yale Professor, researcher and a clinician, pointed out that many patients get only moderate symptom relief from treatment. What they often are very pleased to find is that they lead much more satisfying lives. When their symptoms do return, they cope better and maintain a much better sense of self-worth and self-esteem. They find their symptoms much less burdensome. The quality of life has improved – sometimes dramatically.
Finally, some thoughts on seeking treatment and what one can expect. There are two basic approaches – medical and psychological. If you start with your internist or family physician, you will very likely receive medication. And if you have physical symptoms, you may have to go through a variety of tests to rule-out organic causes. While this isn’t all bad it is often unnecessary and a well-trained psychologist will refer to a physician when appropriate. If the patient selects medical consultation treatment is often limited to trials of various antidepressants or anti-anxiety medications. In my experience, this is far more likely with an internist or family physician than with a psychiatrist, who is a specialist in this field. The pharmaceutical companies have done an excellent marketing job and have convinced many physicians and the public that medication is not only the better choice (over psychotherapy) but also that it is all that is needed.
A number of studies have shown that only about 15% to 20% more patients get complete relief from symptoms with medication than placebos. The research that I am most familiar with indicates that about 35% to 40% of patients get very good symptom relief. However, 15% to 20% of patients do as well with a placebo. The pharmaceutical companies are understandably reluctant to make this information available. Recent news stories make it clear that this reluctance and some cases, out right deception, are not limited to psychiatric medications. Additional research also indicates that, while medication often provides quicker initial relief, it can also become less effective over time. For many people, medications have dramatically improved their lives. Many also have found them frustrating and ultimately unhelpful.
Depression and anxiety are generally chronic illnesses and are seldom cured but nonetheless quite treatable. Think of them as being like diabetes. Although there is no cure for diabetes, diabetics who follow their physician’s treatment recommendations often do very well. They lead relatively normal lives and find that the illness is inconvenient, but not debilitating. Those who don’t follow their treatment, have many more problems with diabetes and generally find their lives shortened. Depression and anxiety are similar in that many who treat the illness and follow a reasonable treatment plan can also lead relatively normal lives. When they do have reoccurrences, they are generally milder and less frequent. As with diabetes, life-style changes play an important roll in reducing the impact of these illnesses.
For most people, starting with psychotherapy with a psychologist, who then can assess your appropriateness and interest in medication, is a more conservative approach. Among the best ways to find a psychologist is a referral from a friend or a trusted professional. Finding one on an insurance list or a web site like this is taking potluck – sometimes good, sometimes not. Quality, competence and “fit” can vary widely. Try to get a referral from a source in whom you have confidence. It is important that the patient feel comfortable with their psychologist. But it isn’t important to feel a deep connection, especially early on. It is important to feel that the psychologist is professional, solid and competent. If medication is indicated, which is often the case, appropriate referral can be made. Research indicates that for many people, psychotherapy and medication together are often the best treatment – as many as 75% to 80% get significant improvement. Several published articles of research also indicate that the longer patients stay in treatment, the more gains they make and, in general, the longer these gains are retained.
If you have read this entire article, I congratulate you. If you are searching for help for yourself or for someone you care about, I wish you the best and would happy to be of assistance.