The Recognition and Management of Depression

Abstract

With at least 20,000 successful suicides reported each year in the United States, the failure to recognize an acute depression may prove to be as disastrolls as the failure to diagnose an impending coronary occlusion, a penetrating peptic ulcer, or an early diabetic ketosis. It should be noted that many die from more acceptable causes such as traffic accidents, ruptured esophageal varices or the cardiovascular sequelae of overwork, all of which may be related to less overt self-destructive tendencies. There are many types of depression; the differential may make for better management. In some cases, however, target symptoms may be of even greater importance since many patients defy differential diagnosis and refuse to be placed into tight diagnostic categories. Neurotic depression and depressive reactions are now classified in the same category,l indicating that depression is a mood to which the human animal is universally vulnerable. The differences in patients lie in the intensity, adequacy and duration of both the stimulus and the response; in the fact that what is relatively innocuous for one is highly provocative for another. In many, the precipitating cause is a loss-of a mate, a leg, a uterus; it may be a financial loss, or a loss by fire or theft. It may also be a loss which is not concrete and not easily identified, such as a loss in self-esteem. Here the provocative event is indeed difficult to define due to the human need for denial. Manic-depressive illness is a cyclic affair. The premorbid personality is cyclothymic, with its characteristic shifts in affect. As the aging process proceeds, depressions may become more prolonged; there is early awakening, loss of appetite and loss of weight, diumal variations, and a potential for suicide. Milder cases are not necessarily psychotic, and are labeled as cyclothymic personalities. Some therapists feel that psychotherapy with the production of adequate insight and rapport can definitely influence the process. Others are just as equally convinced that manic-depressive illness is metabolic or diencephalic in origin,2 yet can nevertheless be influenced by psychotherapy, provided the goals are reasonable.