mixed. there's no one cau of depression, even for a single person. it's unlikely that there is one thing that causes their depression. we think of it as a risk factor model where depression develop in the context of risks. when those risks get high enough, thto develop this lf-sustainindepressiond those risks ght be divided into three categories-- psychological, environmental, and biological. on the biological risk side, we have genetics, other physiological conditions, which give us a predisposition toward becoming depressed. on the psychological side, we have thinking patterns, cognitive style, personality, and various factors like that that may leave us at greater risk for depression. on the environmental side, we have things like stressors and lack of social supports, which leave us at greater risk we have for depression.essors when the sum of these risk factors gets high enough,

that pushes us over some threshold, and we go into a period of clinical depression. for some people, one of those factors may be stronger than the others, but it's unlikely that there is one cause. one it's usually some balance stronger than the others, with different weights on the dferent factors. first of all, the development ofa clinical kia like depressn is a very mplex phenomon. it involves the development, psychologically and physicly, of the individual, and then on top of that, the need to cope wi the sometimes catastrhic social conditions that patients are exposed to. some of the coitions that gary edelein's clients arexposed to arrtd incrsing aun drug helsof vionce. bh he and dr. young point ou all the risk factors must be attended to.

what wreooking at isn'only thecute eosure to a particular all tsocial problem, must be attended to. but the tendency of that individual to have been exposed to oblems all through their live all of this sets up the social stressoren a rear isnflicted upon them, the patient nae cope. 's usually when ty presento us with clear diagnostic different populaons seem to have different kinds of risk faors. to suffer from major depressio areas are men. dr. knafo and dr. fawcett discuss some of the theories about psychological,iologil, anenronmtal faors that may ctre tohidifference. in addion to wen livin inin our siety,gsocial disae we know, and research h shown, that for women,

relationships armore significant than for men. nojust more significant-- and i'm not sang that for men relationships aren't signicant-- but that women are more affecte, by the fate of their reliohips. they define themsees very much according to the relationships that they're in. carol gian, a researcher from harvard, has demonstrated that femininitd through relatedness, while masculinity is largely defined throh separateness. so iany losses otraumas thisin a relationship will be experienced re... more seriously by a woman than by a man-- more depressing. the woman will tend to be more depressed by a loss or a major change in a relationship than a man will be because she defines herself and her success in life

through her relationships. because i uldn't have my own children. th was my first heartbreak. when we adopted our children, i felt le a failure as a mother because i didn't know hoto raise them, if i was raising them properly. i tried copying what eryone else had done, d it wasn't comi true fome. i loved their father so much, i was willing to do anything for him. um...it hurt an um... it's, li, i see him now, once in a while, and i tell him now, "i love u, but it's n the same. "i know when to say no to you. "i can do for myself. i don't have to depend on you." more women come in fotreatment than men. it may be as high as 3-1 in a clinic.

women seek treatment more easily than men. men wait till they're much worse off before they'll get treatment, usually till they can't work. they have a much higher rate of suicide. why do more women have depression than men? itay be because less women are alcoholic than men. men are much more likely to have alcoholism. alcoholism and depression overlap a great deal, so men may become alcoholic as a way of treating their depression. it's aery poor treatment for depression. it makes it worse, t it alls the person to get by for a longer period of time. that may be one possibility-- the overlap between alcoholism and depression. the other reasons may have to do with hormonal differences between men and women. ere are considerable differences, and, you know, women frequently develop premenstrual depression.

women with depression equently get much worse premenstrually. this is not uncommon. so there may be a hormonal difference. there may be many social dierences in terms of social roles concerning women in our society that exert different pressures on them than on men that account for this. along with psychological and environmental factors, experts believe that biology plays a role in botmajor depression and bipolar disorder. there seems to be especially strofor bipolar disorder. rodney belongs to supportroup called mood challenge. rodney's mother diussed her first manic episode. atge 55, i hamy fst one. the ctor said that at was very unusua but i had been under a tremendousot of stress with rodneyand all he h and otr thingsin o life.

i had just been der a t of stress. i didn't know anything unusual was haening to me. there had been a fewights that i hadn't slept, but not too many nights. and, um--i, um... i just felt like i was really into god, but duringllhis time, i had ied toretend that nothing was happening. i justried to shut it off. i thout,i have to do this," beusi had to go toork. you were really into god, and i thought i was god. [laughter] the idea of genetics, right now, is based mainly on the observation of family transmission. that means the occurrence of an illness being more likely if there's a family historyce of the illness.ss now, that doesn't prove genetic transmission. it just suggts it.

somebody looking at the patient's environment could say, "well, the environment's also the same "in thmily, and maybe that transmits the illness." we have reasons to believe from twin studies, where identical twins have the same genetic material, that the likelihood of transmission is much grter. and there's been efforts to identify the genes which have come up with findings which have not yet held up. so we don't have genetic proof, ultimate proof, but the evidence is very strong for genetic transmission in both bipolar and unipolar illness, but it's strongest in bipolar. so rodney probably inherited a predisposition for bipolar disorder from his mother, mostikely a dysfunction in how the brain works. in this highly schematic drawing, nerve cells in the brain carry information in the form of electrical impulses along the length of the cell. for the impulse to cross the synapse--

the space between the cells-- a chemical called a neurotransmitter must be released into the synapse. the neurotransmitters move across the space and lock into specific receptor sites on the next cell. that's normal brain function. the theories of mood disorders-- that includes both depreion and mania-- are dominated today in tod'snowledge base by our knowledge of neurotransmitter function in the brain. in major depression, a person may not have enough neurotransmitter at the synapse. in a person who is manic, there may be too much neurotransmitter at the synapse. summing up, there is no single cause of major dression or bipolar disorder. there are various contributing factors. one--there may be deep-rooted, unconscious conflicts. two--on the biological level, a ficit of neurotransmitters may result in depreson, while an excess may produce manic stat.

ree--there istrong evidence thatespecially bipolar illness-- may be genetically transmitted from one generation to another. and four--some depressions may co aa reacti to life ents, must bconsidered.ctors and four--some depressions unemplment, illness, or theth of loved on may lead to depressi. all or some of these factors y be involved. it is impoant to aess each person individually to deterne what the causes are and what treatments will be most effective. some people with major depression aren't treated because the episode runs its course, they aren't proper diagnosed, or they st d'teehelp. for threst, there are two general forms of treatment-- psychotherapy and medication. phyllis received both. the appropriate use of antidepressant medications has helped many people with major depression. would be a medicationression

which would increase the availability of certain neurotransmitters-- perhaps norepinephrine, perhaps serotonin. we would use medications like the tricyclic antipressants. for instance, elavil or tofranil are well-known medications. as dr. fawcett notes, antidepressants increase the level of certain neurotransmitters. there are two kinds of medications that accomplish this-- the tricyclics and the mao inhibitors. for a long-tm mood disorder in which biology is a major causal component, such medications can often work wders. the problem is they don't work for everyone who takes them. the dosage must be watched carefully. there can be dangerous physical and psychologicalside . any medication you may take will have side effects. the importan of the side effects has to be measur against the benefits of the medication,

and the cooperation and motivation of the patient is extremely important. i depended on too much of it at fir. i thought, "i'll ver be sad again. i'll nevbut i was wrong.in." medition can on do much. u have to start to make ur own rovery onk thugh the road, and yohave to d you have to mend every brge that you've broken. for some peoe, medication ienough, and some get better without any treatment at all. many others need and can benefit from psychotherapy with or without medication. in therapy, people examine how their life experiences and early events have affected them. for some time, this has meant psychodynamic psychotherapy, a model in which unconscious conflicts considered to be at the heart of the depression are uncovered.

where dr. bailli is the mical director, margarita iso usesed psdymic principl. would y at depression was real nnly the angetued inward, buit was theest of the conict between her ger, heaggression e husband,and soher confliing e, io and dependency on the hband that creates a cflict whic, for the pat, unresolvable and results in thejust psychologilly ving up, and that's t clinical manifestation of depression. focuseson the identifation of thiagessive impulse and thdetandin of how it's being rechneled and nflicted so twh the patnt understands atin a more clear wa

e's able toaccehe feengand unded that it's appropriate and human feeling and doest meanthe feengand unded she will deprive herte of that dependency object. today, iaddition to psychodynamic psychotherapy, the are meew short-terpsychothe. right. different individualsnees and even different types of psychotherapy. we talk about psychotherapy as if it's one thing, but there are many different types of psychotherapy. not everybody should have psychoanalytic psychotherapy that has a depression. some people need it. some do better with a cognitive form of psychothapy. it takes some expert judgment to decide what aerson needs. anyone who evaluates people with depression should be familiar with the different types of therapy available and make a decision on an individual basis what a patient needs in each case. everybody wants simple answers to this question--

either/or, one or the other. that's not how it works with human beings. there's been advancement in the past 1o, 15 years for psychotherapy and depression. the two that have erged as being demonstrated by research to be effective in depression are cognitive behavioral therapy and interpersonal psychotherapy. those are both types of therapy which were, at least originally, specifically developed for depression and were specifically developed to work in a prescribed period of time, usually two to three months. the theory of cognitive therapy is that our feelings and our behaviors are determined by the way we think about things. so, for example, if someone criticizes something i y, and en iight ask you, "how am i ing to feel when that happens?" it's impossible to answer that without knowing what i think about having been criticized.

the depressed person has negative evaluations of themselves, tends to put a native cast on ents that happen, a negative view of the world and future, and therefore feels and behaves in a depressed way. so the way we tranate that into therapy is tidentify with the person the thoughts that they're having, not an analysis of the psychodynamics or the psychological processes underneath like you might in traditional therapy, but just what their thoughts are. and then with them, we evaluate whether there are distortions in those thoughts, whether there are alternative ways of thinking about the situation, alternative beliefs that they might have, and alternative ways of behaving that might yield different results. with them, we evaluate those thoughts and beliefs, look for changes that can be made, have the people do behavioral experiments where they do something in a different manner than usual

as a way of changing their evaluation of what's going on, changing their thoughts, and if their thoughts change, their feelings will naturally change in response. i now know that when i starto think about something d, i say to myself-- that my psychiatrist has given mekills along with the help that i' had from moodhallenge, like, uh, you'reeally not this bad person. u did this, but you' able to take the responsibility for it now. i don't see psychotherapy and medication as an either/or question. some patients that have more-severe depressions won't get better, in my opinion, without medication... in the more severe level. many patients need both psychotherapy and medication to fully recover from their depression. there are a few people

that can have even severe deessions who have intact personalities, who can be treated with medation and some supportive psychotherapy and recor without any further need for therapy. there are those people, but that is not to say that you can replace psychotherapy with medications in patients who ne both. you simply can't do it. i would say that reay looking at the whole person involves our r not falling into a particular ideological position, but utilizing all of the knowledge that's available to help our patient. when patients are so depressed that they can't function, or they're suicidal and haven't responded to drugs or other therapies, many professionals think that e.t.-- electroconvulsive therapy-- may be the only option left. how e.c.t. works isn't fully understood. a convulsion is produced by passing an electric current ugh e brain.

in 8o% of those who receive e.c.t., the depression lifts within weeks. e.c.t. was first used as a tatment for depression in 1938. the controversy that surrounds it is the result of its history of overuse and even abuse. in the 194os and 195os, e.c.t. was widely used in mental hospitals, often indiscriminately. patients experienced long-term memory loss, bone fractures, and heart attacks. in the 196os and 197os, e.c.t. fell out of favor, replaced by psychoactive drugs, but psychiatrists were faced with the problem of treating severely depressed patients who didn't respond to medication. e.c.t. has been making a comeback. there are changes. length and intensity of electrical charge have been duced, as have the numb of treatments. patients are given strong muscle relaxants to prevent broken bones, and they are carefully monitored.

[electrical humming] in spite of these changes, there remain critics who think that the possibility of long-term memory loss is a high price for relief of severe depression. the percentage of people with major depression who require e.c.t. is small. for the majority, psychotherapy and medication prove effective. for bipolar disorder, the same is true. here, treatment usually involves thadministtion of e ug thium carbate and some fof psychrapy. the patient who has manic-depresve illness asar as know, s it for life. like diabetes or any other metabolic illness that's genetic, they have it for life, which means they could have an episode anytime during their lifetime if they're unprotected. there is protection to prevent episodes in the vast majority of cases,

and the most standard protection is lithi carbonate, although there are other new medications we have for patients who aren't protected by lithium carbonate. i think the quality of my life today has ver been any better. lookg back, even a year ago, i was unemployed. any better. i didn't know what i was going to be dog. it's just kind of evolved. i'm spiraling up, anit just has worked out great. i'm managing my illness... um, you know, with lithium. i take 1,2oo milligrams a day. the likelihood of recurrence with just average treatment-- that includes people who don't take their medicine-- the 5-year risk of recurrence is close to 8o%. for those who take their medication as prescribed, only 2o% to 3o% will have a recurrence over a two-year period. even with medication, psychotherapy may be an important part

of their overall treatment. dr. knafo relates the history of lester, a bipolar patient. he had a long history of depression. he'd had several manic episodes for which he'd been hospitalized. so here he was hospitalized this time. he was about the age that his father was when the father had committed suicide. in the hospital, lester was treated anparticiped in psychodicsychotherate with dr. k.work had tbe in terms of separati lester's identy from that of his father's and in allowing him to mourn his father's death. in his family, emotions weren't tolerated. he was never allowed to grieve his fath's death. evenmoved out of the hospital and back into society. in addition to medication and psychotherapy, self-help groups, like mood challenge in peoria,

n offer social suppo to tho who areoping with mood disorders. at you have to remember is that the illness affect different people differely. just because you have certain sensations doesn't mean that it affects other people the same way. we tend to tunnel vision from our viewpoint. rod's mania may have been entirelyifferent than mine. there's an awful lot of similarities, don. there's a lot of similarities, i think, from just talking with you about yours. my son, unfortunately, isn't in as good shape as rod or you. he's still struggling with trying to get this under control, and right at this moment, he's in a depressed state. he's functioning, going to work, but that's all he's doing. he comes home from work and goes to bed. the other members of the group

have been through what i've been through. they know what i'm feeling. they know the questions that i face, uh, about the medication, about treatments, about reestablishing my life in the community, um, because the majority of them have been there, and...and you just can't get that anyplace else. we have talked about two types of mood disorders-- major depression and bipolar disorder. for both categories, the episodes can range from mild to severe. when mild, other people wouldn'know that there's anything wrong. when severe, total incapacitation can occur. there are many theories about what causes depreson and manic-depression. one-dimensional explanations are inadequate. we must evaluate risk factors-- psychological, biological,

and environmental-- and the complex ways they interact, and then assess each person individually to determine which treatment or treatments would be the most beneficial. 1 in 1o americans will experience a mood disorder. the good news is that in most cases, mood disorders can be successfully treated. whoa. whoa. night and day. i mean, that's a real easy way of saying that "before, we lived in darkness, and now we live in light." it's a real easy way of sing that because it's like, ok, it's like this is-- once there's a name, once there's a label, it's like, "it's not me. it's not her." you can let it go. you don't have to ell on what could have been. it's kind of like a catharsis in the cocoon. it's like, "ok, we're free."

she's happy. i mean, i could never disagree with her at all, and now i can disagree with her, tell h i disagree with her, and she still likes me. it's like, "all right!" i think i'll keep her! stick around! i do a number of things, i guess, just when the mood strikes, and it's n the mood disorder. i like to... just two weeks ago, i went scuba diving down in my parents' lake and really did my first open-water dive there, and, uh...that was a great experience. uh, you know, i like to bicycle ride, and i'm involved in competitive volleyball at the "y." that usually carries over for about nine months. it will start again shortly, and i'm excited about that.

i just really-- i mean, i love life. i think i have such a pitive outlook. uh, there's-- i n't think of anything i don't like to do.ok. if i haven't done it, i'll try it, you know? captioning performed by the national captioning institute, inc. captions copyright 1991 alvin h. perlmutter

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