Depression and women

National Women's Health Report, August, 2003

To Sondra Fine *, 48, depression feels like this: "I have been immobilized, unable to formulate thought or action. Can't get out of bed most of the time. I feel terrible--hopeless, joyless, exhausted, lost."

To Terry Wise, 39, depression feels like this: "A world of apathy, a world where nothing is enjoyable, where food doesn't taste the same and the colors don't look the same."

To Esther Nitzberg, in her 60s, depression feels like this: "As if there's a weight, a shroud, a dark cloud that follows you around."

These are just three voices of the more than 12 million U.S. women who suffer from depression, (1) a disorder that strikes women nearly twice as often as men.

Depression is a wily disease, sometimes camouflaging itself as anger or fatigue, sometimes sending you to sleep all the time, or keeping you awake all night. It can come on suddenly or sneak up on you gradually. It also is a dangerous disease. In 2000, 29,350 people in the United States killed themselves. And while four times as many men as women die by suicide, women attempt suicide two to three times as often as men. (2) Plus, depression is strongly linked with other illnesses, such as heart disease and osteoporosis--diseases that women are at high risk for developing.

The good news: depression is one of the most treatable diseases doctors see. There's just one problem: people suffering from depression often don't receive adequate treatment, according to a major new study published in the June 18, 2003 issue of the Journal of the American Medical Association (JAMA).

Researchers in the study, only the second nationally representative sample of depression ever conducted in this country, held face-to-face interviews with more than 9,000 randomly selected people to determine whether they had any history of depression, the quality of the treatment they received and any other mental or physical conditions they experienced. (3)

"The real surprise," says the study's lead author, Ronald C. Kessler, PhD, professor of health care policy at Harvard Medical School, "was that well over half the people surveyed with depression had severe depression, and only 10 percent were considered mild to moderate." Yet just one in five received adequate treatment. These are the people who can't get out of bed, who seriously think about killing themselves, who can't function--people like the women described at the beginning of this article. "We're finding that less than half of them are even getting minimal treatment," Dr. Kessler says.

In the JAMA study, treatment was considered adequate if it consisted of at least eight, half-hour sessions of counseling with a mental health professional, or treatment with antidepressant drugs for at least 30 days combined with four visits to any type of physician, per depressive episode. These mirror federal guidelines for the treatment of depression by family practitioners, says Dr. Kessler.

Treatment Barriers

So why don't people who are depressed receive adequate care? One reason is they may not look for it. "There's still a very large stigma attached to mental illnesses like depression," says Steven D. Hollon, PhD, professor of psychology at Vanderbilt University in Nashville.

It's also not easy to find help, says Dr. Kessler. "There's a lot more confusion in mental health treatment than in the physical health arena," he notes. For instance, if you break your arm, you know exactly where to go for treatment; but it you feel depressed, you might choose anyone from a family practitioner to a social worker Making it more complicated is the fact that physical complaints such as vague aches and pains, which can also be symptoms of depression, may go undiscussed or undetected. (14)

It took visits to every therapist and psychiatrist in the small Oregon town where she lives before Ms. Nitzberg finally found what she calls "a straight-talking psychiatrist who is willing to give me low doses of medication in the combinations that work best for me."

If you're having trouble finding a doctor you like, check with the nearest academic medical center. Physicians there are usually tip to date on the latest drugs and therapies, often conducting clinical trials on new treatments. If finding the right medication is a problem, consider seeing a psychopharmacologist, a psychiatrist who has received additional training in the medications used to treat mental disorders.

But, finding treatment is only half the battle; the JAMA study also found that the treatment itself might be inadequate. For instance, many people interviewed in the study who had depression received just 5 milligrams (mg) of an antidepressant that should be prescribed at 20 mg. That's consistent with other studies showing that primary care physicians and nurses, who treat 70 percent of those with depression, tend to under-prescribe medication for depression, says Dr. Hollon. They also tend to keep patients on the wrong dose or wrong medication for too long before trying other drugs that may be more successful.