Dealing With Depression

By: Manuel Wertman  

I. Changing Climate 
The awareness and acceptance of depression as an illness has increased in our community over the years, as we have been educating ourselves about many medical conditions and their treatment, including psychiatric conditions. More than 10% of adults experience depression any given year and 16% of adults will experience depression in their lifetime. Psychiatric disorders, however, are still associated with a level of stigma in our community, much different from other medical conditions. Consequently, many people still go untreated and endure needless pain and suffering. The purpose of this article and the accompanying articles in this issue of The Jewish Observer is to continue to educate our community about some of the most prevalent and most debilitating diseases that affect so many of us. And to provide hope for those suffering from these conditions that treatment is available and effective. 

Not Just the Blues 

Depression is much different from the "blues" and the sadness we all experience from time to time. Most of us are quite resilient and can cope with these transitory periods in our lives using our natural supports: our inner strength, our friends and families, our bitachon in Hashem that "gam zeh ya’avor." The focus of this article is the kind of depression that should be evaluated by a competent mental health professional who can assess the severity and the duration of the symptoms, and the extent of disruption to the individual’s life. 

Depression has no single cause, but often results from a combination of factors. Whatever the cause, it is related to an imbalance of chemicals in the brain, and must be treated like any other serious medical condition. Depression is a disorder that involves the body, mood and thoughts. It affects the way a person eats or sleeps, the way one feels about oneself and the way one thinks about things. While there are other "mood disorders" that readers have heard of, such as Bipolar Disorder, in this article we will discuss only depression. 

II. Common Symptoms 
Some people say that depression feels like a black curtain that covers their lives. People who experience depression, however, often feel that their lethargy and inability to fulfill their life roles, whether as spouses, parents, workers, etc., is a sign of personal weakness. They feel guilty that they can’t just snap out of it. Family members may be impatient and critical, and demand that the individual "get over it" and fulfill their responsibilities. Relatives may not understand the depth of their loved one’s suffering and that the person cannot just pull him or herself out of it. 

Other Symptoms 

Depression of more than a very mild degree is regularly associated with other symptoms. Many people who visit their doctors with complaints of insomnia, fatigue, weakness, or lack of energy may actually be suffering from depression. Some experience frequent backache or headache. Sometimes people complain of "nerves" or irritability. Likewise, these symptoms may be related to an undiagnosed depression. People who are clinically depressed often have lost interest in or pleasure in nearly all activities. They may have lost their appetite, have difficulty thinking or concentrating or making decisions. And most seriously, people may have frequent thoughts about death or suicide, and may have plans or make attempts. 

Depression can be thought of as an exaggerated sadness coupled with pessimism; a sense of hopelessness about the future is a major component that distinguishes depression from the ordinary "low" feelings that we all experience from time to time. The depressed person is not simply sad; he has the impression that his sadness will persist indefinitely regardless of what he does about it. 

Young children who cannot describe their feelings easily may instead demonstrate hyperactive or aggressive behavior. They may describe frequent physical symptoms to avoid going to school. They may lose interest in playing with friends and have frequent crying spells. And, like adults, they may look sad and have changes in sleep and eating patterns. Sometimes parents will be able to identify a precipitating event such as a serious illness or death of a family member or other traumatic life event; sometimes a clear precipitant is lacking. A visit to the child’s pediatrician can rule out any physical problems and if indicated, lead to a referral to a qualified mental health professional for a complete evaluation. 

Adolescents may experience depression as uncharacteristically staying away from friends or loss of ability to concentrate in yeshiva. Rebbeim may report that the talmid has lost interest in learning, or that he seems to daydream a lot, or that he lost his sense of humor. Some adolescents may express their depression via "off the derech" behavior. Undiagnosed and untreated, this expression of a depression is of course potentially extremely dangerous. 

Women are almost twice as likely to become depressed as men. This higher risk may be due to hormonal differences. Many women face additional stresses, such as responsibilities both at home and at work, and caring for both children and aging parents. The issue of depression in women is more fully discussed in an article by Dr. Hindie Klein elsewhere in this issue. Men, however, are more likely to go undiagnosed, and they are less likely to seek help. Men may mask their depression through displays of anger or hostility or the socially acceptable habit of working excessively long hours. The elderly are more at risk of losing spouses and having to adjust to living alone. Physical illness and disability may result in dependence on others which may contribute to depression. Older people may not receive the treatment they need for depression because their symptoms may be misinterpreted as normal aspects of aging. Sadly, some people have the mistaken idea that it is normal for the elderly to feel depressed. On the contrary, most older people feel satisfied with their lives. It is especially important for us, as a people who respect our elders and value the mitzvah of kibbud av ve’eim, to make sure we recognize depression in late life so that treatment can make those years as enjoyable and fulfilling as possible, for the benefit of the elderly person, as well as for his family and caretakers. 

Some types of depression run in families; however, it can occur in people who have no family history. At any age, depression can be precipitated by illness, by hospitalization, by surgery, or by other major stress. It can occur following a major life event, such as loss of a loved one, loss of employment, or persistent shalom bayis because of shalom bayis problems. 

In summary, what distinguishes clinical depression from the ordinary ups and downs of life and the normal ways we respond to daily stress is that in depression, the changes in mood are experienced as overwhelming or crippling; this feeling persists for an extended period of time, and the individual experiences difficulty in fulfilling his or her daily routine. 

III. Treatment 
The first step in obtaining appropriate treatment for depression is a thorough physical examination by a physician. Certain medications and some medical conditions can produce the same symptoms as depression. The doctor should rule these out through appropriate tests. He can then make a referral to a psychiatrist, psychologist or social worker. 

A good diagnostic evaluation will include a thorough interview with the patient and his or her family. This will involve a comprehensive review of the history of the symptoms, previous treatment history, family history and related questions. 

The treatment choice will depend on the outcome of the evaluation. There are a number of options. Some people with milder forms of depression may do well with psychotherapy or talking therapy alone. As Shlomo HamelechMishlei: "D’aga be’lev, ish ysichena" or to paraphrase, a person with something on his mind should discuss it with someone else. Two of the most effective kinds of psychotherapy are Cognitive Behavioral Therapy (CBT)and Interpersonal Therapy. CBT can help to identify and change the thought and behavior patterns that contribute to depression. Since people who are depressed tend to think negatively, CBT teaches how to identify and challenge the negative thoughts. Interpersonal therapy addresses depression that can be connected to troubled emotional relationships. Short-term psychotherapy is more and more common, and may occur over a period of 10-20 weeks. 

Those with more severe cases of depression most often benefit from anti-depressant medication. Many studies have shown that for most people, a combination of medication for relatively quick symptom relief, and psychotherapy to learn more effective ways to deal with life’s problems, is the most effective approach. At this point, it is important to note that for pharmacological treatment, there are many good psychiatrists available both in the frum community and non-frum or not Jewish. Those individuals seeking a therapist for talking therapy, however, should strongly consider using only a frum therapist who is sensitive to all the subtleties of the issues that a frum patient may raise in their sessions together. Rabbinical guidance in this area is recommended. It goes without saying that the therapist should be an experienced, credentialed and competent clinician who is highly recommended. Even so, one should also evaluate if the therapist who is recommended is the right match for you. The success of therapy depends to a great degree on establishing a good relationship between therapist and client. 

In conclusion, one of our obligations as Torah Jews is to watch over our health. In order to live a life of Torah, mitzvos and gemillus chassadim, we must make every effort to stay healthy. This includes our physical health as well as our mental health so as to be whole, and to enable us to perform our avodas Hashem. 

Manuel Wertman Serves As Director of Mental Health Services in Ohel Children’s Home and Family Services in Brooklyn.