I have received several criticisms from colleagues about my position on describing depression as a brain disorder that is biologically based. This is a controversy all area and a political one. Many in the mental health profession feel that to medicalize depression is to play into the hands of the pharmaceutical industry. I think there is great merit to my colleagues points and I accept their criticism that my focus on depression may be too narrow. Maybe. So I'll publish excerpts of their letters and then my response at the end.

Dear Dan,

It seems that every time I read your column lately, you re making the case for depression as a biological illness like diabetes hat requires medication. I certainly agree that medication can be helpful for some people with "deep depression" you referred to recently. However, as you know, many people in our field feel that medication is being vastly over-prescribed. (Dr Joseph Glenmullen at Harvard says in his book that 75% of prescriptions for Prozac are unneccessary.) Young people are being taught that the answer to life's problems is found in pills--long before they have the chance to develop coping skills that would serve them far better and without side effects.

The point you made that distressed me most was that "depression is caused by a chemical imbalance." However, no such imbalance has been found for depression. Some depressives have low levels of serotonin, but others have normal or high levels. The drug companies themselves admit

that their anti-depressants offer results just mariginally better than placebos.

It's possible that you and I will never see this situation quite the same way. I've seen so many patients who come in severely depressed but who decide to use psychotherapy alone to get well.

Here's my point and my plea: Pharmaceutical companies have vast sums with which to deliver their message to the public, and they do so round the clock, reaching many millions daily. The other side of the debate gets zero air time. How can the public be expected to weigh the evidence?

Can I respectfully suggest that you read someone from the other side : eg Dr David Healy ("Let Them Eat Prozac") or Glenmullen ("Prozac Backlash")

Deborah Anna Luepnitz, Ph.D

Dear Dr. Gottlieb,

A couple of months ago, and again recently you indicated that depression is due to a biochemical imbalance for which medication must be taken. While I am not against the use of medication under certain circumstances, I wish to raise a question about the biochemical imbalance idea. It is often invoked these days as an explanation for depression as well as for other emotional problems, as if it were an already proven certainty. Yet we both know that there is another side to the story, an equally legitimate point of view that rarely finds its way into the public purview. The pharmaceutical industry has spent a considerable amount of time, effort, and money promoting its wares, as it should. It must show profits and it must answer to its shareholders. So we would expect that they will present a polished portrayal of their products. However, as clinicians, we must be careful not to solely rely on them for all of our information--much of which they derive from research which they themselves have funded-- regarding the efficacy and safety of those very same products. This is not a novel perspective. It is a point that has been made by Angell, Editor of the New England Journal of Medicine, as well as others

Right now the public, as well as some professionals in the field, believe that there is only one option when faced with emotional problems, that of medication.

Respectfully,

Burton N. Seitler, Ph.D.

Both of my colleagues make very important points. And I agree that medication is overprescribed and that, as our culture, we are too ready to look for pills to solve our problems. And, of course, much of this is fed by the pharmaceutical industry. So I agree with all of the exploits.

And I did mention in my last web chat that both medication and psychotherapy individually get comparable results, but both together get even better results.

However, I disagree about depression not being based in genetics and brain chemistry. I am quite comfortable with the research about that. And to view depression as a brain disorder goes a long way towards taking much of the shame and stigma out of the diagnosis. Unfortunately, both still exist as many see depression as a character weakness or a failure, but I find that once I explain to an individual or a family the biology of depression, shame dissipates and people are more likely to seek treatment -- both medication and psychotherapy.

Now that we know more about the brain and genetics, more people are seeing it for what it is -- something that originates in biology and can be made better or worse depending on what happens in one's environment. Just like there is plenty of evidence about the biological basis of depression, we now know through various scans that things like meditation, prayer, psychotherapy also change brain structure and function.

I appreciate your criticism, it helps people learn more .

Dan will be joined by a mother whose daughter suffers from depression.

If depression affects 20% of our population, then the number of loved ones touched by this illness probably includes most of us.  So what can we do when a loved one is depressed and refusing treatment?  Case in point is "distraught mother" below who will be joining me on Tuesday's web chat.

Hi Dr Dan

I enjoyed reading your column, but your last one on "the depths of depression" spoke to me directly.  This subject is of particular importance to me because over this last weekend, I discovered that my eldest daughter has fallen again in a deep depression.

My husband & I struggled to communicate with her about her need to seek treatment. Then your article appeared in the paper. Very timely. She has 4 babies with the youngest one-year-old, and after each one, and she had a postpartum depression.  Her husband works long hours which I am sure adds to the stress.  We live in another state which makes us feel more helpless and frustrated. 

 Her situation is very stressful, but is compounded by the depression which has developed since she stopped taking her medication about 8 weeks ago. That's because she has a history of eating disorder and she feels the medication is making her put on weight. Lately she has been cutting herself off from everyone.  But the most frightening part occurred last week when she called me hysterically crying and said she did not want to be a mother anymore.  As she is an adult woman and I know I cannot force her to take antidepressants. My question is, what can I do to convince her to get treatment before she hurts herself or her children? The situation seems dire, please help. Distraught mother

Dear distraught mother,

Any good parent can understand the desperation you must feel.  After all, our primary instinct is to protect our children.  That only gets magnified when we have grandchildren.  Okay, by now you probably know my mantra about releasing our grasp on adult children, and not being reactive to our own anxiety and helplessness.  All of which is true -- until it happens in your family. 

Although you cannot control your daughter's behavior or even her thinking, you also cannot be passive as that last phone call sounded desperate and dangerous.  So I would suggest doing two things simultaneously.  I know she is seeing a therapist every other week, but he/she should be notified right away about your daughter's desperation.  I don't know the laws in the state where she lives, but in some states that threat might be enough for outside agencies to intervene and get her into treatment.  Her husband also must know how desperate the situation is and some things he can do.  For example, he can contact their local county office of mental health to find out what they have available.  Also national organizations like National Alliance of Mental Illnes(NAMI) and the national mental health Association (MHA).  In addition, it would help if friends and family could spend time in the home helping with child care as having four babies would tax anyone's emotional resources. 

So one route you can take his aggressive intervention with agencies and support networks.  But that is not the only route. I also have other suggestions.  And here I don't speak just as a family therapist, I speak as a father.   When my daughter experienced depression for the first time, she was a young adult and living independently.  Just like your daughter, her symptoms started in childhood when she would isolate herself.  And just like your daughter as she grew and the depression worsened, she began to engage in behaviors that were of concern to me and the rest of the family.  And like your daughter, whenever someone said anything about her behavior, she became defensive.  She lived within driving distance so I asked her if I could come up and just hang out for a day. This may or may not be a possibility for you.  But if it is, I urge you to consider it.  Anyway, as  I was driving to her home, I thought back to when I specialized in substance abuse.  I recalled that their families thought the problem was drugs or alcohol, and the abuser thought the problem was the family!  And then I realized that I had been thinking the problem was my daughters’ depression and her behavior while she was thinking that the problem was everyone else.We spent the whole day together exploring her new neighborhood, visiting her worksite and hanging out with her animals.  We didn't talk about her depression or the risky behaviors she was engaging in, we just talked about her (okay, and me also).  For the first time since the crisis began, I felt close to my child and I am sure she felt the same with me. It was then that I asked her about how she was feeling about her life and herself.  And then I listened for a long time.  When she was done, I told her that her suffering broke my heart and that the reason she suffered was because of her genetic-based illness called depression. I almost cried when she looked up at me wide-eyed and said "I thought everyone felt this way." 

Although medication and psychotherapy combined are the treatment of choice for depression, there is also plenty of evidence that family therapy helps.  If you or your spouse have had depression I am sure an open discussion about your experiences, your impulses and your coping strategies would help diminish some of the shame your daughter feels.  And very often beginning with family therapy helps the person with the symptoms feel less like "the sick one".

Keep in mind that despite your terror, what she really needs from you is intimacy, safety, trust and love.

I don't typically remember my dreams and when I do, they are rarely memorable.  But there are a few notable exceptions, and last month I had what some might consider a prophetic dream. 

I was in a crowded subway minding my own business and pretty quickly the crowd began to hurriedly leave. Finally, there was about five of us remaining and I could see why they left.  The angel of death was standing there looking slowly at the five of us.  And yes, he looked a little bit like a malnourished Darth Vader with a boring black wardrobe and a sickle.  He looked carefully at each one of the other four frightened people and told them to leave.  And then he looked at me and said: "January".

And then I woke up.

Once began thinking about the dream, I wanted to go back as I had so many questions, like: "what about January, are you telling me that will be the first snowstorm, Eagles will be in the Super Bowl again, I will be taking a vacation to a warm climate so maybe I should buy my plane tickets now?"

Just kidding, I knew what he meant.  January is when I will face my death.  So the big question would be which January?  And what if it is this coming January?

although I sometimes take dreams literally, usually they are metaphorical and often a manifestation of one's unconscious for an unexperienced mood state.  But as I thought about the dream, it didn't feel like it was symptomatic of depression or anxiety like many are.  

So I decided to spend the next several days assuming that this January will be my last, and so will this spring and next summer.  As will encounters with friends I see rarely. Even those I love dearly, I began to see them as though I wouldn't have much more time with them.

And you probably know by now what happened. This spring has been one of the most precious and vibrant I've ever encountered.  My love for people in my life has grown in depth.  And while everything I love feels more fragile, it feels more precious at the same time.  Just like life itself.

Like I said, that dream was a month ago and that vibrant awareness of my fragility comes and goes.  But when I do experience it, I feel more alive and grateful.

So was that dream about me or was it an archetypical dream that is really about all of us?

Now that I experience the gifts of that dream, I sometimes think maybe I should send that guy a thank you note.  But he was pretty weird and might take it the wrong way.  And that's the last person I would ever want to piss off

Join Dan and his guest Steve Newman in a chat about clinical depression. The chat starts at noon. You can post your questions now.

For those who have never experienced clinical depression, it can be hard to understand. For most people, it is just a depressed mood, something most of us get over in a brief period. With a bad mood, most people can function with a pretty clear mind. It can be painful, but no big deal.

But for about 20 percent of us who have or will experience clinical depression, it's a very big deal. Clinical depression affects the way we think and the way we experience ourselves in the world. It affects relationships and our ability to accurately interpret information.

A young woman I treated years ago said that she felt like a diamond inside a malignant tumor and didn't know if she would live or die.

A recent colleague said  he felt as if his brain were oatmeal and that he couldn't think properly.

When I suffered clinical depression, I felt like a frightened, confused child pretending to be a psychologist. And feeling like a sham made the anxiety, depression and shame so  much worse.

Steve Newman had his first episode of depression when he was in seventh grade. A good student, he had a precipitous drop in grades and felt lost for much of his youth. Although his IQ was measured in the top 10 percent nationally, he graduated high school in the bottom five percent of his class.

When I spoke with him, he said his poor transcripts reflected the efforts of someone who didn't expect to live more than a few more years. Somehow, his father got him into a local college which is where he first heard the word "depression."

He said his depression felt like climbing a mountain when a storm hits. Any thoughts of going upward were beaten down by cold rain and wind. Going down was also impossible because of the same elements. He said his goal in life was just hanging on.

A colleague once told me that depression is experienced from the outside in, that people on the outside can see it before the depressed person knows it.

 Such was the case with Steve. That was true for me too.

Mine started several years after I became a quadriplegic as I felt my wife pulling away. My mind began to race and I worried all the time. I felt increasingly insecure and said almost nothing in meetings, fearful that what was occurring inside would become visible on the outside.

But I didn't even know I was depressed until one of my nurses told me that I looked as if I had the weight of the world on my shoulders. Once I realized that what was going on inside my head was visible on the outside, I knew I was depressed and sought treatment.

Depression can affect a litany of things from sleeping and eating patterns to concentration and memory. It can induce guilt and a feeling of worthlessness.

And although only a small minority of those with depression attempt suicide, it's not unusual to think about wanting to die. I recall thinking that life was just too difficult and painful to go on. I didn't want to die, but my suffering was unbearable.

There are many types of depression. The causes, too, are varied, but most have a genetic link. I had a mild predisposition as there was dysthymia, a low grade form of depression, in my family. Steve had bipolar disorder in his family.

Most people with depression get better with treatment. And gold standard care for depression is a combination of medication and psychotherapy.

Prognosis is tied directly to the duration and frequency of episodes. That's because depression has a powerful negative effect on the brain and the longer it lasts, the more likely one is to have a second episode. And once that happens, patients are at far higher risk for even more episodes.

My depression diminished significantly with medication and psychotherapy. And when I see the first sign of depression, I'm on the telephone with my psychopharmacologist.

Steve has not been so lucky. He has what is called a drug resistant depression and although he has tried almost all medication and several kinds of psychotherapy, he still suffered.

In 2005 he heard about the Transcranial-Magnetic Stimulation program run by John P. O'Reardon at the University of Pennsylvania. This program has recently been approved by the FDA and uses magnets strategically placed near one's scalp to diminish depressive symptoms.

It's another promising treatment for an illness we're all still struggling to understand.