"An open letter to my sisters: why don't we get help for depression?".

Abstract: This feature article, addressed to African-American females, offers a detailed discussion of the various aspects of depression, outlines typical symptoms, and discusses factors that place African--American women in a high risk category. The author includes a discussion of stress and its role in diseases like depression. She then discusses treatment strategies including a discussion on medications and misconceptions. The article concludes with some remarks on achieving wellness, a holistic term for total body health, and challenges African American women to overcome their fears and embarrassment about seeking help for depression.

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Depression, my sisters, is not racially or ethnically based. It is, however, somewhat discriminating sexually. Studies have consistently shown that women are considerably more likely to acquire the disease of depression than men. In addition, women of color, as compared to white women, often have additional stress and risk factors, which in turn increase their risk for depression (Pouissant and Alexander, 2000). Although women are more likely than men to seek help for this illness, women are still victimized by stereotypes and stigmas that perpetuate the suffering. As a result, depressed people can become trapped in a world filled with sadness, despair and hopelessness, believing that they must live with this illness. Believing that there are no other choices.

Let's talk about depression, the disease. First, I am not talking about simply having a bad day or a bad week. Nor am I referring to those occasional moments of sadness or despair when you wonder where the next breath will come from in order to make it through the day. No, as difficult as these times are, they may only be symptoms of depression but not necessarily the full expression of the disease.

Depression is a disease, a medical illness. It is the result of abnormalities in the brain that appear to be caused by extended periods of stress and duress, from which the brain is unable to reestablish its normal mood. It is actually a "multi system" disease, meaning that, since the brain controls multiple functions or systems, when impacted by depression, many of these other functions are affected. The result is a disease with a variety of symptoms that can interfere with a wide range of daily activities and functions.

Depression is also a chronic disease. This means there is no cure, only control of the illness. Studies from the National Institute of Mental Health as well as the Centers for Disease Control have listed various statistics relating to which populations are more likely to experience a reoccurrence of their depression, following a single episode. However, regardless of whether one suffers from a single episode or is at risk for reoccurrences, it is important to know that depression, like other chronic illnesses including hypertension and diabetes, can be controlled with comprehensive medical treatment. This will be discussed below.

Depression can also be genetically based. Like diabetes, heart disease and other chronic illnesses, it can run in families. Along with evidence of a relationship between alcoholism and depression, there are socioeconomic factors including economic class and marital status, which seem to create an increased risk as well (Klein and Wender, 1994). The presence of concurrent physical illnesses serves as a stress factor that can precipitate a depressive episode. Given a combination of these risk factors and the presence of unremitting stress, it is not surprising that the development of a depressive episode becomes "an illness waiting to happen."

However, without straying too far from understanding depression, let's explore, for a moment, the issue of stress -- the culprit with which many ills and illnesses seems to be connected. Yet, stress like the air, is all around us. Exactly when does it become the source of our misery and pain and why?

It is somewhat useful to think of stress as those elements in the external world that create specific physical changes within our bodies, changes which can, over an extended period of time, lead to disease. Stress causes the release of "stress hormones", including cortisol, serving as a trigger to help the body respond appropriately to stress and then to overcome it. In the short run, this is positive and necessary for survival. However, chronic stress and the repeated exposure of the brain to "stress hormones" can lead to changes in the body which do not return to normal when the stress is removed. It is like running your car's engine in the red zone -- do it on occasion, and with a return to normal driving, the car's engine will return to the safe zone. Continue this behavior indefinitely and ultimately you will need to replace the engine. Your body, and in this case your brain, is much like the car. Over an extended period of time, operating in the body's "red zone" of stress, along with the presence of certain risk factors, significantly increases the possibility of developing depression.

Does all stress lead to disease? Not necessarily. However, there is a high probability that this can happen, given the right combination of factors. Long-standing or chronic stress can place certain individuals at an increased risk of developing the disease. Consider, for example, the impact that the following stressful events could have on the mental functioning of a woman:

* a childhood of abuse and/or neglect;

* a work environment with excessive demands and little happiness;

* financial difficulties which are both overwhelming and limited in solutions;

* years in an abusive adult relationship;

* the loss of a loved one whose death is too painful to think about.

The list is as diverse as the lives we lead. These factors alone, however, may not necessarily, cause a severe depression. Other risk factors play a critical role as well.

Research continues to report that women, before menopause, are at greater risk of developing depression when compared to male populations in the same age group (Stewart and Robinson, 1997). New and evolving research is suggesting that the brains of women, from the time of the developing fetus, may be physically different from those of men (Lerner, 1998). This difference, it is suggested, may actually begin in the developing fetus when sexual differentiation occurs. Later, with puberty, we know that the hormones estrogen and progesterone become major players in the women's physical and emotional health. Changes in a woman's mood are often directly related to her menstrual cycle and these changes, in turn, may be the result of fluctuating levels of estrogen. When these changes occur to the extreme, significant health problems can arise, including premenstrual dysphoric disorder -- a severe case of PMS, as well as depression and anxiety disorders. Some research also suggests that, following menopause, women who have never developed a severe depression may not be at any greater risk of developing depression than men, at the same age (Stewart and Robinson, 1997). This again may be related to the effect which estrogen has upon mood.

In my practice I am always amazed at how often people begin by stating,

"I really thought this was something I could handle."

"I feel so weak, like I have failed."

"I should be able to control things so I don't get depressed."

Often people will tell me that others have made especially cruel remarks to them including:

"You don't have anything to be depressed about."

"You just need to make yourself get out (or get up or get over it)."

"I was depressed and I got over it - so should you."

I often wonder if the people who made these remarks to a depressed friend or loved one would have made similar remarks if they had been addressing someone with cancer, diabetes or heart disease. I don't think so.

Unfortunately, we still operate out of prejudice and ignorance when it comes to diseases of the brain or, as the more archaic name refers to it -- "mental illness." This is an especially serious problem in the African American community. We have historically sought treatment less often, have been much sicker when we were finally forced to seek care and have had fewer treatment options when health care was needed. The reasons are not surprising.

Diseases of the brain have always carried a social and cultural stigma. These conditions continue to be seen as a sign of weakness rather than illness. It has also been historically difficult for African Americans to trust health care providers, due in many cases to a history of inadequate, discriminating, and in some cases, inept and inappropriate care. With "mental" illness, the African American community was especially skeptical of treatment. Along with the shame and embarrassment of these conditions were the fears, and at times ignorance, of what having a mental illness meant. We therefore endured the problems, relying upon what seemed our only options - prayer and private suffering. However, when we are talking disease, serious disease, I strongly believe that both "prayer and pills" are needed in order for health to be restored.

There has been, and continues to be, a lack of adequate community resources and support necessary for the comprehensive and successful treatment of depression, especially in poor and under served communities (Surgeon General's Report, 1999). Many times when women visited their physicians complaining of "feeling depressed," they were ignored, their complaints minimized or worse, were afraid of being considered "crazy" -- an especially derogatory term which is still quickly and derisively employed throughout this culture. Many African American physicians have been reluctant to refer their patients to psychiatrists as well. This may be out of concern that such a referral would create the impression that the doctor also believed that the patient was "crazy" and their complaints without real merit Too often even the physicians have been unwilling to recognize these conditions as diseases and have blamed patients instead. This of course creates feelings of guilt and helplessness that have only compounded the suffering.

What then is this disease called depression and when should someone seek treatment? With depression, there are well-established guidelines and criteria for making the diagnosis. (The American Psychiatric Association, 1994). Much like the National Cancer Institute has done for breast cancer, the National Institute for Mental Health, in partnership with numerous consumer and professional organizations, has created materials which define for the public those "warning signs" for depression. In general they include the presence of the following, in any combination, for at least 2-4 weeks:

* Depressed mood most of the day, nearly every day;

* Decreased interest or pleasure in one's daily activities;

* Major changes in weight and/or appetite;

* Insomnia or hypersomnia;

* Agitated or slowed thinking;

* Fatigue, loss of energy -- all activities seem to require excessive effort to complete;

* Feelings of worthlessness, inappropriate or excessive guilt;

* Decreased ability to think or concentrate; indecisive thinking;

* Recurring thoughts of death or suicide; this does not always include a wish or plan to die but the belief that "others would be better off without me."

This list highlights the more prominent features of depression but it is not all-inclusive. Many women complain of being easily frustrated, irritable or angered, worried about their "lack of patience with my children or my spouse." Others report not wanting to talk with friends, citing their lack of energy or interest in doing so. Their answering machine becomes their sentinel, screening their calls and limiting their interactions. Their ability to function in the work place is also seriously compromised. There are complaints of problems with memory, concentration, attention and recall. Their productivity is greatly reduced and in many cases, individuals who at one time were outstanding employees now risk losing their job.

It never ceases to amaze me how, in view of the debilitating character of this disease, depressed women eventually find their way to me. It takes incredible strength, courage and faith to seek our treatment and then to commit oneself to it. As my patients regain their health and express their appreciation for my help, I remind them and myself, that they are the ones responsible for what has happened in treatment. Without a doubt I have provided direction, support and success in controlling the disease, but each of them has had the more difficult task of living with the impact of this disease until treatment was successful.

Which seems to bring us to the question of treatment -- what works and why? My experience, after 15 years in private practice, is that treatment works but it doesn't work the same in every individual. Treatment must be individualized. Medications for depression are safe, effective and must generally be continued for at least a year once the depression is controlled. The patient and her physician should then determine together whether it is time to discontinue medications and/or change the approach to treatment.

Questions and confusion about taking medications often create the greatest concerns in patients. Between the bizarre and often scandalizing stories promulgated by the media, talk shows and individual "experiences," one can easily accept the skepticism of the public as healthy and appropriate. But just as we have a right to be skeptical, we have a responsibility to know the facts and to separate facts from fantasy.

It seems that just as we, in the African American community, are gaining access to health care and to healthier selves, others within the community would move to suggest we should not accept such care, labeling it as either dangerous, "politically incorrect" or brainwashing. Our history of past victimization by the health care industry in areas of access to care, resources, research, unethical practices, etc. should continue to generate the need to be well informed prior to undertaking treatment. However, this search for truth and safe health care should never be done at the expense of good care. Safe and effective treatment for psychiatric illnesses is available. Unfortunately, access to competent, caring and fully trained physicians, including psychiatrists, is not always available.

As for the medications themselves, let us clarify some common concerns. First, antidepressant medications are not addicting. Many women say to me that "I don't want to get dependent on this medicine -- I don't want to be addicted to it." This is a valid and important concern. What needs to be understood is how dependency and/or addiction develop and which medications can create these conditions.

There is a distinct difference between taking drugs because you want them and taking medications because your body needs them. The first is a psychological dependence often leading to addiction and the second is a physical need generated by the body's inability to normalize functioning without the medication. Much like the need one might have for hypertensive medications because the body is unable to maintain normal blood pressure without them, so is there a need for antidepressant medications as the brain is unable to maintain normal mood without them. However, should the time come when this problem has been overcome, then the medications may be able to be discontinued and the disease controlled without them.

Treatment with medications, however, is only a part of the process. Just as "talking" therapy does not resolve a depressive illness, so it is also true that medications alone will not restore wellness. What is required is a full commitment to changing lifestyles, exploring and changing coping mechanisms, and understanding those factors that created the problem in the first place. It is this subsequent phase of treatment, of talking with a professional, which is critical to maintaining health and wellness once the depression is controlled by medications. My approach to treatment has always been to first restore health with medications as indicated and then to create "wellness" by identifying and changing lifestyle issues which may have contributed to the development of the illness.

In promoting wellness, I start with certain fundamentals. First, we must learn to love ourselves, fully and completely. It is my belief that, as a child of God, it is my responsibility to love and respect his work through me and in me. I can only do that if I believe in myself, that I see myself as special, and as a tribute to the Almighty, that I take full responsibility for my health and well being. If we focus upon ourselves and make our health and happiness our priority, then the natural outcome will be the happiness and well being of those whom we love and care for. Neglect ourselves and everything suffers. Care for ourselves and everyone benefits.

The steps for achieving wellness begin with a personal inventory of one's life -- eating habits, exercise patterns, the spiritual self, relationships at work, home, with friends, family, and other aspects of one's lifestyle which give pleasure, joy and satisfaction.

Addressing those factors that have gradually stressed the brain to the degree that a depressive illness has developed will create an understanding of where one's efforts for change should be directed. However, such a necessary "journey" of understanding cannot be fully successful if one is struggling against a severe depression. Therefore, I advise my patients to recognize that the healing process may take some time, there is no quick fix to the situation, and that once the medications have become effective, there will be a renewed interest and strength in the ability to reestablish a normal life. Patience and faith are critical factors in this healing process.

In summary, let me again express my deep concern about the level of suffering which is occurring within the African American community and especially with African American women because of untreated depression. The Surgeon General, Dr. David Satcher, in 1999, released the first Surgeon General's Report devoted solely to the issue of mental health and mental illness. Hopefully, by identifying mental illness as a national health care issue, reports such as this will help to erase the stigma against treatment and increase the opportunities for competent and successful care.

Depression is a disease and it does respond to treatment. However, this condition will only be controlled when the right to comprehensive health care is coupled with the responsibility to seek treatment in an intelligent manner, educating ourselves on what is needed to achieve wellness and then committing ourselves to maintaining it.

REFERENCES

American Psychiatric Association (1994). Diagnostic and Statistical Manual of Mental Disorders (4th ed.). Washington, DC: American Psychiatric Association

Klein, D. and Wender, E contributor. (1994). Understanding Depression: A Complete Guide to Its Diagnosis and Treatment. New York: Oxford University Press

Lerner, H. (Executive Producer) (1998). Out of the Darkness: Women and Depression. (Videotape). New York: Creative Expressions Inc.

Mental Health: A Report of the Surgeon General (1999). Retrieved January 2001 from the World Wide Web: http://www.surgeongeneral.gov/library/reports.htm

Pouissant, A., Alexander, A. (2000). Lay My Burden Down: Unraveling suicide and the mental health crisis among African-Americans. Boston: Beacon Press.

Stewart, D. E. and Robinson, G. E. eds. (1997). A Clinician's Guide to Menopause. Washington, DC: American Psychiatric Press.

The following resources are offered for additional reading on the subject of depression:

Boyd, Julia A. (1999). Can I Get a Witness? Black Women and Depression. New York: Dutton/Plume.

Danquah, Meri Nana-Ama. (1998). Willow Weed for Me: A Black Woman's Journey Through Depression. New York: Ballantine Publishing.

Ernst, E., Rand, J., Stevinson, C. (1998). Complementary Therapies for Depression -- An Overview. Retrieved January 13, 2001 From the World Wide Web: http://www.drrob-md.medem.com.

Mitchell, Angela and Herring, Kennise, contributor. (1997). What the Blues is all about: Black Women Overcoming Stress and Depression. New York: Perigee.

Yapko, Michael D. (1997) Breaking the Patterns of Depression. New York: Doubleday.

Additional recommended Internet resources for current and continuing information on depression and other mental health issues are:

American Psychiatric Association- http://www.psych.org

American Psychological Association -- http://apsa.org

Depression and Related Affective Disorders Association (DRADA) -http://www.med.jhu.edu/drada

National Mental Health Association -- 800-421-4211. http://www.nmha.org/index.cfm

Black Psychiatrists of America - Executive Secretary-Cynthia Thomas. 404-696-1433.

Saundra Maass-Robinson, M.D. is an Associate Clinical Professor in the Morehouse School of Medicine. Address all correspondence to Dr. Maass-Robinson at Morehouse School of Medicine; Department of Psychiatry and Pediatrics; 1372 Peachtree St. NE Ste. 105; Atlanta, Georgia 30309; Ph: 404.873.3111; Fax: [phone]; Email: [e-mail].