When the clown stops laughing.


clown1The death of Robin Williams has created a worldwide outpouring of sadness and grief that I have not often witnessed. Though we all know how closely linked depression and comedic skill can be, it is still difficult for many of us to fathom how a man that could have given us such great joy could have been so bereft as to kill himself. In Williams' case, it is made even more difficult because his humor was delivered impromptu, directly from his heart and soul. How does the playful, energetic, insightful man that we saw onstage become locked in such despair? To understand, we need to look beyond the trope of the clown with tear-stained makeup and into the blackness that, to a certain degree, we all carry within. Just as there is no yin without yang, there is no joy without despair. But what is often overlooked is that the manifestation of depression is highly variable, and no two depressions are alike. Thus, we cannot approach their management in all the same way.

Some depressions are what I call "contextual depression." That is, they stem primarily from the your attempts to cope with a difficult, albeit temporary, environment. The loss of a loved one through death or divorce, an abusive work environment, severe financial stress -- all of these are situations in which depression begins as an appropriate adaptive strategy, but due to duration, or repetition, it becomes self-destructive and the behavior can continue long after the trigger that caused it has gone.

On the other hand, some depressions may have no obvious precipitating factor at all. This form of insidious depression works its way through you in the form of negative self-talk or the erosion of an impossible perfectionism slowly stripping you of, first, self-esteem, and eventually, hope. Not only is this depression subtle in its appearance to others, you may very well hide it from yourself until it has reached what may appear to be unmanageable proportions.

A third form of depression is a "physiological depression." This is a longstanding, moderate depression which does not have its origins in behavioral or neurological influences at all, but is instead caused by a chronic, debilitating and undiagnosed disease or infection, which in turn creates behavioral changes. Researchers who have watched the behavior of sick animals have noted that the symptoms of chronic, low-level illness are virtually identical to depression: Energy depletion, appetite changes, sleeping changes and behavioral changes which favor energy conservation and protection of vulnerabilities.

While the link between depression and health problems such as MS and back pain are well-known, often overlooked are diseases such as chronic gastrointestinal disease or gland hypofunction whose only visible symptoms are those of depression. Astute investigation on the part of the clinician is necessary to uncover these hidden causes of depression.

All of these forms of depression may be accompanied by substance abuse, creating a feedback loop that increases the severity and complicates the management of depression.

Too often, though, these various causes of depression are overlooked in favor of the cookie-cutter solution of pharmaceuticals. It is true that antidepressants can lift the veil of despair for some people, so the pharmaceutical solution cannot be discounted. But, as several meta-analyses of SSRI drugs have found, the effect of SSRI drugs is much smaller than we are led to believe. This is not news. The first such study was published over a decade ago. "Listening to Prozac but hearing placebo," examined 19 clinical trials incorporating over 2,300 patients, and concluded that SSRIs are primarily placebos.

"Virtually all of the variation in drug effect size was due to the placebo characteristics of the studies," the researchers concluded. "The effect size for active medications that are not regarded to be antidepressants was as large as that for those classified as antidepressants, and in both cases, the inactive placebos produced improvement that was 75% of the effect of the active drug. These data raise the possibility that the apparent drug effect (25% of the drug response) is actually an active placebo effect."

Several follow-up analyses have confirmed this initial study's findings. It is also worth noting that the monoamine theory of depression, which supposedly explains the mechanisms by which SSRI's work, has never been supported by the research.

So these drugs, while they can be invaluable for some people who suffer from depression, are more likely to be expensive placebos for the majority of people. What can you do if you are one of this majority?

The first thing is, see a mental health professional -- and by this, I don't mean a psychiatrist, whose primary skill is in pharmaceuticals, but a therapist, social worker, or psychologist, who can approach depression with a much bigger toolbox than that of the psychiatrist. They can help you develop the insight and skills to help you manage your depression.

Some of these skills include the ability to break down the monolithic wall of despair into more manageable chunks. Recognize and remind yourself that depression is a temporary condition, and you have the ability to influence how long it lasts. You can also reduce the size of your depression by converting generalizations about yourself and your life into specific, limited observations. The thought that "I'm a failure" creates an insurmountable hurdle to overcome -- after all, how could you, you're a failure! On the other hand, recognizing that generalization of failure stems from the fact that you lost your job creates a much smaller roadblock. You may have lost one job, or even several -- but that doesn't mean you cannot find another one.

One of the best ways to shorten the duration of a depressive episode is through physical activity. Though it may seem extremely hard, such simple things as going for a walk or a bicycle ride can change the course of the disease. Physical activity actually changes the neurological functioning of the brain in ways that inhibit depression.

And if you can't help yourself, what about helping others? Perhaps you can't find your way to feed yourself, but maybe you can help out at a food kitchen just a couple hours a week. Research has shown that when we nurture others, we also nurture ourselves. And if you are depressed, such sustenance is the best you can find. Helping others is true soul food.

There are many, many other ways to find your way through depression. And if you are thinking of suicide, reach out for help. It's there. Even if you can't find anything else, call 911.

Dr. Avery Jenkins is a primary care chiropractic physician specializing in helping people with chronic disease. He can be reached at alj@docaltmed.com.