Saturday, February 22, 2014

Depression = Anger + Grief + Trauma

Many years ago, when I started my psychiatric training in Europe, I realized that mental illnesses happen to those people who are not allowed to work through their emotional issues. It was then an acknowledged scientific fact that stress events in life triggered depression and other psychiatric conditions. But how does unexpressed emotions turn into an 'illness' is something that mainstream medicine still has difficulty with.

One of my first success stories in treating depression was a lady who had been on antidepressants and who had won money in a lotto game. In her case the money was the trigger for making her depressed. After taking her history, it emerged that she had more to her depression than the immediate event that was the trigger. She had not grieved over the death of her father. She had been angry with her then husband, who was threatening to separate. She had also undergone traumatic experiences at the hands of her relatives that she had not come to terms with. To my surprise, when the impacts of the causes were neutralized, not only did she come off antidepressant successfully, but she remained well without medication for many years till I lost touch with her.

Another story that I remember was of a time much earlier than the above event. A mother in her early 40s used to attend the psychiatric services for the treatment of depression. She was on antidepressant medication for many years. She was not willing to come off medication. She had an excellent upbringing and a good personality. She had lost her child many years ago in an incident that she stated was not a suicide. It was an incident that had shaken her own belief regarding her abilities as a mother. Despite the efforts of the doctors, she was unprepared to allow herself to grieve over the loss of her son. She continued to suffer with depression.

Most of the time the individuals who suffer with depression, have learnt to hold back their anger. This anger could be due to many causes. The commonest one is against one' s parents. Though parents do their best to bring up their children, the children tend to carry some anger or annoyance about their parents. This anger gets compounded if there are elements of neglect, rejection or threat. Other factors are the parental strictness and disallowing the child to cry or express themselves emotionally in any form. The anger is then suppressed. Other life events like bullying and strict teachers add on to the anger. If the person has seen other crises in their lives, anger increases.

Unresolved and unfinished grief is the other cause for depression. Anger and fear of the departed is the main reason for the grief to remain unfinished. This happens especially in the cases of abuse when the abuser is a close relative who has died. Unresolved grief is commonly seen in all forms of abuse.

Traumatic events can occur in many forms. I once saw a lady having unresolved trauma from an accident that took place 25 years ago. She was under the impression that the event had resolved itself as it had occurred many years ago. On remembering the event a few times, she started to have aches and pains in precisely the same spots in the body where she had felt pain immediately after the accident. She was obviously surprised, but she learnt that an event that happened many years ago is not necessarily forgotten by the body even if we believe that we do. Traumatic events can be repetitive, like abuse, or they can be sporadic events like rape or road traffic accident or a physical assault. Each of these experiences individually, can be the trigger for depression. They can also affect the body and the mind in a subtle manner and one may not experience any major depressive event for a long time in life.

A common complaint that family physicians encounter is- persistent and chronic fatigue with loss in interest and excessive sleep. This condition, when it occurs without any physical illness, is termed chronic fatigue syndrome. Fibromyalgia is another term currently used for similar symptoms. These conditions have the same causes, in my experience, as major depression.

Depression, from clinical perspective, is diagnosed when a person has low mood with reduced concentration, reduced ability to enjoy day to day activities and reduced energy that has lasted for more than two weeks. The person may have a loss of appetite, with a reduction (sometimes an increase) in weight. Sleep may be interrupted or the person may wake up two or three hours earlier than usual wake up time. There may be guilt or a death wish especially if the person has a sense of hopelessness about the future.

Dysthymia is a term that is used to describe long-term sense of feeling low that does not disturb the sufferer's life in a major way. The quality of life is low because of lack of enjoyment. This condition is diagnosed when it has lasted for at least two years.

In all the above cases mentioned, antidepressants are the main line of treatment in psychiatry. But if the anger, grief and trauma issues are addressed, medication is easy to come off. In most of such cases, the person may not need antidepressant treatment again.

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