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Aug 2006

By Marion Scher

We've all had days when even getting out of bed is a mission. But where does a bad day end and depression start?

Barry Swartz was 33 when he had the worst day of his life. Then he had it again. And again. And again. After a while, he felt like a character in Groundhog Day, with every day seeming just like the last. Things just never seemed to get better. He tried to change his circumstances. He bought a guitar to learn to play music but never quite got up enough energy to find a teacher. He found another job, but that only made things worse. His new employer expected him to drive tour buses through the night, which left him shattered for days. "I was permanently exhausted," says Swartz. "I had difficulty falling asleep and, when I did drift off, I'd wake up with nightmares."

As the months progressed, the dreams got worse. He lost his appetite. Then, one day, he woke up and started crying uncontrollably. Unable to stop himself, he eventually called his mother in despair. She took him to see a psychiatrist, who prescribed antidepressants.

The weeks that followed were dangerous for Swartz. As the antidepressants started working his energy improved, but his mood remained dark.

It's the sort of story that makes you think, Man, couldn't he just pull himself together? Some of us can, but some of us can't. For Swartz, those interminable night shifts triggered something that had been lurking in the shadows for months. For the next guy, the onset could be more sudden, the trigger the sudden death of a close friend, a mild drug experiment or being the victim of crime. The truth is, we never really know how we're going to react to any given situation and if you look at the figures, you feel kind of vulnerable. The latest statistics on depression show that one in four people will suffer from depression and one in 10 from panic attacks during the course of his or her lifetime.

What is Depression?

Depression is more than just that down feeling you get on a Sunday evening as you contemplate the week of work ahead. It is a deep and sometimes debilitating decline that can leave you feeling unable to meet the demands of your day or enjoy the things in life that you once loved the most. It can emerge out of nowhere or it can be triggered by an unpleasant experience that causes a chemical imbalance in your brain a shock powerful enough to change the way your neurons behave.

Studies show that depression is linked to changes in the normal functioning of brain chemicals, called neurotransmitters. There are several different neurotransmitter systems that can be involved, but the two normally associated with depression are serotonin and noradrenalin. Serotonin governs our moods, emotions, sleep and appetite, while noradrenalin excites neuronal receptors in the brain. When levels of these substances drop, it causes depression. Antidepressants restore imbalances in these neurotransmitters.

So depression is not just a case of feeling a tad sad. It's a psychological illness, like diabetes, that causes a change in your biological make-up. And when you can't shake a severe case of the blues you should begin to seek help. The problem is that very few men do. For most men, the mere mention of "psych" as in the words "psychiatrist" or "psychologist" sends shivers down spines. "We see so much depression," says psychiatrist Dr. Sheldon Zilesnick of the Crescent Clinic in Randburg, "but sadly few men come looking for help. Women find it easier to admit they have a problem and want to talk about it.

"It's the 'illness' concept of depression that worries men but what they don't understand is that depression is treatable. Antidepressants are very effective."

There's the other problem for most guys a dislike of pill-popping, especially to tranquillise the mind. "There are so many myths about antidepressants because people simply don't know what they are or how they work," says Zilesnick, adding that people often confuse antidepressants with tranquillisers such as Valium, which are addictive. "People think if they're on antidepressants they'll be walking around like zombies, but the opposite is true. Today's antidepressants can, where needed, give you back a normal life and are definitely not addictive. They're not the chemotherapy but the antibiotics of psychiatry. There may be side effects, but today these are usually mild and don't last long."

Treating Depression

Donovan Miller, a 31-year-old from Cape Town, was a typical antidepressant sceptic: "I thought I could beat my depression on my own. My GP suggested I was taking strain at work and gave me a sick note for a week." His doctor also put him on sedatives, which helped him sleep but left him feeling sad and anxious.

"Looking back, I now know I've always suffered from depression, even as a child." He felt a constant need to please other people, coupled with a pressure to succeed. But it was only after a bad work experience three years ago that he crashed. A friend persuaded him to see a psychologist and he went twice a week for a couple of months. "This helped me open up to my past and work on my future, but I was still crippled by a constant fear of failure."

After two months of therapy, Miller realised he needed to do more than just reflect on his past. His psychologist referred him to a psychiatrist, who prescribed Efexor, an antidepressant that has given him back his life.

The best treatment for depression is usually a combination of therapy and drugs, says psychologist Kevin Bolon, a specialist in cognitive behavioural therapy. "If the depression is mild to moderate, a six-week course should be enough. If we don't see any improvement, medication is usually prescribed."

He explains that cognitive behavioural therapy is good for lifting a depressive mood and helping a person improve his problem-solving skills. "When you're depressed you see problems as mountains as looming catastrophes. With cognitive behavioural therapy, people learn to recognise and correct what have become totally distorted or irrational patterns of thinking, which often causes the depression in the first place."

Mood Disorder

To complicate matters, depression is often mistakenly diagnosed when the real problem is Bipolar Mood Disorder.

There are two types of Bipolar Mood Disorder in psychiatry: Bipolar I and Bipolar II. The second type, Bipolar II, looks very similar to depression but is punctuated by "hypomanic" episodes mild highs during which the person actually feels quite good. "Most people don't know Bipolar II and so the symptoms aren't easily picked up," explains Zilesnick. "Many people think bipolar is a very severe form of depression, but it is a completely different illness that is totally unrelated in that it can occur in someone who's never had depression."

During a hypomanic episode, a person with Bipolar II experiences a degree of happiness that's totally out of proportion with what's going on around him. The problem is that the person almost always crashes into depression afterwards and the condition gets worse every time. Doctors often only identify Bipolar II when the "depressed" person doesn't respond to antidepressants.

The other type of Bipolar Mood Disorder, Bipolar I, used to be known as manic depression and is marked by extreme changes in mood, thoughts, energy and behaviour. A person's emotional state tends to alternate between extreme highs and extreme lows, with a "mood swing" lasting anywhere from hours or days to weeks or months. Like Bipolar II, Bipolar I has no clear cause, although the illness tends to run in families. It can lie dormant until a trigger such as recreational drugs or a trauma sets off a manic or depressive episode. Often there is no identifiable trigger.

Usually, men with Bipolar Mood Disorder first shoot off into mania, while women first experience depression. Mania sounds like a great night out, actually. You feel energetic and confident. You're convinced you're the smartest guy in the room. You can go for ages without needing sleep. It would be fun, if you didn't also suffer from delusions of grandeur, aggressive behaviour, impulsivity and spectacularly bad judgement. And going without sleep for three days is never good, no matter how much work you think you can get done.

As a result, a typical bipolar in a manic state will throw in his job in a fit of impudence, buy an expensive car using the kids' education fund and have unprotected sex with five women in one night just because he can. In extreme cases, he may also experience hallucinations.

A Manic Man

Just ask Braam Meiring of Pretoria. Life was pretty good for him until three years ago, when mental illness turned his world upside down. "It was on my thirty-first birthday that I had my first manic upset. I'd had a couple of bouts of depression before, so although I felt a bit down I never thought there was anything wrong. In my case, my manic behaviour causes me to think I own the world. I become abnormally assertive."

That day he found himself wandering into a movie house that was advertising the movie The Sum of All Fears as a forthcoming attraction. It's about a CIA hotshot who hunts down a group of terrorists who plan to detonate a nuclear device. In his manic state, Meiring managed to convince the movie house employees that, if the movie was shown in Africa, it could encourage that type of terrorist behaviour here.

"In my gratitude, I gave each of them a watch. In fact, giving away things was what I did every time I had a manic episode, which would last a week or more. Every face I saw was the face of God. At the end of the episode, I realised what I'd done and felt like the lowest form of life. By then I realised something was wrong and desperately wanted help."

His bother had him committed to hospital, where he was prescribed Lithium, a drug used to treat manic episodes. Within three or four days he started to recover, but he remained in hospital for about two months. He remained on medication after he got out, but has had a couple of manic episodes since.

Getting Help

The South African Depression and Anxiety Support Group, founded over 10 years ago by Zane Wilson, has seen a gradual increase in the number of men seeking help from the organisation.

"One of the biggest problems with anything associated with the words mental health is the stigma attached," says Wilson. "People feel once their bosses or friends know they're on medication for depression or anxiety they'll look at them in a different way, or worse they'll get overlooked for promotion or lose their jobs. It's perceived as a sign of weakness. And to overcome their feelings, many men turn to alcohol." This is the irony of any psychiatric illness that it takes grater bravery to seek help than to hold on to the mistaken belief that you have everything you need to solve your problems right there inside your head.

But what if that is exactly where the problem lies? What if your brain, as an organ, has its weaknesses, just like every other organ in your body?

Think of it this way: if you were diabetic, you wouldn't think of using willpower to fix your pancreas. You would adapt your eating habits and take insulin. Similarly, you wouldn't expect to cure high blood pressure by the sheer force of concentration. You would exercise, cut back on salt and pop whatever pills your doctor prescribed. So why the resistance to fixing one's brain in the same way?

South African Depression and Anxiety Group
Tel (011) 783 1474
Website

Copyright 2006. Used with permission from Marion Scher.

Article featured in Men's Health, August 2006.