Chronic Depression: Disease or Charcter Flaw?

A major survey on depression symptoms from the National Mental Health Association (NMHA), released in july 2001, revealed a dramatic degree of progress in public understanding. Yet even amid this promising trend, the survey sheds light on the difficulties faced by millions of people striving to manage this sometimes chronic, life-long illness.

The NMHA survey shows a major shift in public opinion in the last decade about the cause of depression. A majority (55 percent) of those polled who have never been diagnosed with depression symptoms understand depression is a disease, and not "a state of mind that a person can snap out of." In 1991, only 38 percent recognized depression as an illness.

The survey also sketches a troubling portrait of the socio-economic lives of some people with depression symptoms. Survey respondents with depression symptoms reported higher levels of unemployment and divorce than respondents who don't have the disorder.

"We set out to get a snapshot of the state of depression and its treatment," said Michael M. Faenza, president and CEO of the NMHA. "The good news is that there is greater public understanding of depression and that people living with depression are finding substantial relief by following their treatment plans. The challenging part is understanding the degree to which public perceptions impact those in treatment," said Faenza.

In this year's survey, nearly one in three Americans say they believe depression symptoms is a state of mind. "Fifty-five percent understand the truth about depression. That is good, but it is not enough," said Faenza. "You'd never hear 31 percent of the population deny that diabetes and heart disease are real. Erroneous beliefs about depression fuel stigma, bad public policies and poor personal choices by those living with the illness and may impede their recovery."

The survey also describes a strong correlation between clinical depression symptoms and diminished social and economic circumstances for families. Survey respondents with depression report greater rates of divorce and unemployment than the general public. What's more, respondents who have experienced multiple depressive episodes are even more likely to be divorced or unemployed. They also are more likely to have lower income and educational levels. The NMHA survey, conducted by Public Opinion Strategies LLC, comprised interviews with 500 adults currently being treated for depression, 300 primary care physicians, psychiatrists and psychologists and 800 members of the general public.

Gap Between Knowledge and Behavior

Survey respondents who are living with depression symptoms overwhelmingly feel that treatment, including medication, psychotherapy or both, works. (Their average self-rated symptom severity dropped from 8.5 before treatment to 3.6 within six to 12 months after starting treatment, using a severity scale of one to 10, with 10 being the most severe.)

Yet people are finding that staying with treatment is hard work. While they seem to understand the value of long-term treatment (in fact, most respondents believe that adhering to treatment is not difficult) nearly one-third (29 percent) of people on antidepressants report skipping doses during the week and nearly one-fourth (24 percent) have difficulty attending regular psychotherapy sessions. However, physicians and psychiatrists surveyed believe adherence is much lower than people in treatment profess. Almost 40 percent of doctors believe those they treat have difficulty staying with their medication regimens (a number consistent with most studies), and half (52 percent) say those they treat have difficulty staying with their psychotherapy regimens.

The survey suggests many reasons why some people don't stick with treatment. In addition to struggling with the nature and demands of the depression symptoms, they may find the requirements of long-term vigilance overwhelming. A majority of doctors (70 percent) say those they treat for depression symptoms might find adherence easier if they could take medication less often. But medication is not the only issue. Though people with depression symptoms believe diet and exercise to be beneficial to long-term wellness, they nevertheless report not adhering with these regimens either.

"The survey clearly shows that the fewer episodes of depression people reported, the more likely they were to have stayed with treatment, whatever that treatment may be," said Faenza. "Facing up to this illness and taking personal responsibility for its treatment are vital. Yet some may not acknowledge and seek treatment for depression because of negative public attitudes and misperceptions."

In fact, even as people with depression symptoms struggle with the illness itself, they also seem to be searching to determine their best course of treatment, how long they should stay in treatment, what they might expect from treatment and whether they will ultimately recover. As a result, more people are employing a combination of techniques to get and stay well.

Perceptions Diverge

Public perceptions about depression symptoms often diverge significantly from the perceptions of people in treatment and may discourage them from seeking effective therapeutic approaches. For example, the survey results showed that the general public ranks regular exercise, a healthy diet and psychotherapy higher than medication for effectiveness in warding off future episodes of depression symptoms. In contrast, doctors and people in long-term treatment rate staying on medication as the most effective way to prevent a relapse, even as they seek the right mix of psychotherapy and lifestyle choices.

Perceptions also diverge when it comes to understanding what treatment can deliver. Thirty-five percent of the general public believe that a person can be cured completely of depression symptoms, a belief held by only 12 percent of people in long-term treatment for the illness. It is likely that many in this group are struggling to achieve realistic expectations for treatment because the majority of subjects in the survey sample are in long-term treatment for multiple episodes of depression symptoms.

About half of those who experience depression symptoms will never have another episode; half will. The findings suggest that people treated for clinical depression symptoms understand the frequently episodic nature of this common illness. More than three-quarters (76 percent) believe that they will need some type of treatment for the rest of their lives, and most understand that their treatment will control, but not necessarily cure, their depression symptoms. However, even as more people come to terms with the long-term demands of depression symptoms, too many still find it difficult to make a treatment plan work for them. "The upshot is that people living with depression conduct highly individualized searches for the right mix of therapies-medical, psychological or lifestyle. The last thing they need is for stigma or public misperceptions to diminish their efforts," said Faenza.

Source : National Mental Health Association, July 11, 2001

Charles Donovan is a study patient in the investigational trial for vagus nerve stimulation and chronic depression. He testified at the FDA Panel Meeting on June 15th and is the author of the upcoming book: Out of the Black Hole: The Patient's Guide to Vagus Nerve Stimulation and Depression.

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