Understanding Depression: What We Know and What You Can Do About It

DePaulo, J. Raymond, Jr., M.D., and Horvitz, Leslie Alan. New York: John Wiley & Sons, 2002. Hardback, 304 pages; also in paperback.

J. RAYMOND DEPAULO JR., M.D., TALKS ABOUT HIS LATEST BOOK, UNDERSTANDING DEPRESSION
Dr. DePaulo, Henry Phipps Professor and Director, Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine was interviewed by Wendy Resnick,R.N., M.S., Director, DRADA Support Services Program. The entire interview was first published in Smooth Sailing, DRADA's newsletter and makes references to DRADA's beginnings. Excerpts are included below.

What is the audience that you wrote the book for?
As we do say in the book, there are three kinds of audiences:
- One is patients with depression or bipolar disorder who may want to know more about their diagnosis and/or their treatment;
- Family members who also may want to know about the diagnosis and treatment of their family member, or how to get someone into treatment or whether it’s likely they have an illness; and
- People who are not in treatment and may want to know if they should be in treatment, or anyone else who is interested. This book, as my previous book, How to Cope with Depression has been, could be used as an adjunct to a classroom text for certain classes.

What would you like readers to take away with them?
The thing I wanted to emphasize in this book that is the same as in my first book, is that depression is a treatable medical disease. Though we do not know exactly what happens in the brain to cause it, we know that it is a brain disease of some sort. We don’t have a specific abnormality in the brain that we can point to, and we don’t know what genes and what in the environment interact to cause the disease; based on our real-life experience, we know that it is a treatable disease with both medications and psychotherapy.

I want people to know what we know and also what we do not know. I wanted to underscore our limitations in knowledge in this book to give a context for what we do know. The inspiration for what I actually wrote came from a DRADA support group for family members in Timonium. What I saw, to my great surprise, was a very high level of distress similar to what you and I first encountered when we started DRADA, in the 1980s. I saw that the anger and distress hadn’t changed as much as I imagined. Here we are in a DRADA group and these family members—struggling with the illness in their loved ones—were feeling a lot of frustration. I was stunned and wondered why this anger wasn’t yielding to all the good information and support now available. Members of the group were frustrated with doctors, administrators of the schools, and the mental health system. Then, towards the end of the meeting, two or three veterans of the group reminded the more frustrated and distressed members that “we all need to know our own limits so that we have something left to give to our family members.” They said, “You don’t know the limitations that the doctors and other professionals are working under, and if you did, you might understand a bit more.” Then I got it! The members did not under-stand the limits of what they and their doctors could do.

For us doctors, the most significant constraint is our knowledge of what to do. Administrators and schools, too, have limits to their knowledge and their resources. I remembered that when I would try to answer patients’ questions, so often the answer was, “We don’t know the answer to that question.” We don’t know why a treatment works, when it works, or how it works. We do it based on experience or based on empirical trials. We doctors would help the patient by letting him or her know that we do not know everything. We should make clear what we know and what we don’t.

Why is it important to get your message out—how we conceptualize these illnesses?
The Hopkins message is that this is a disease and certainly we are not alone in that message. Most psychiatrists agree with that idea. What we bring to it is an emphasis on reasoning—if it is a disease, what does that mean, is it certain, and what other alternative formulations are there? In fact, when you do see a patient, knowing that they have a disease is rarely a sufficient understanding of their problem. To understand the impact of the disease on a person, you need to know a lot about the person’s background, their normal temperament, their personal goals and their behavior patterns—in order to develop a comprehensive treatment plan. I want to reassure and orient patients and families so they can act more independently and effectively in their own best interest.

Where will the book fit into the bigger picture of the many books about mood disorders?
There are hundreds of other books. This one is my personal consultation. I tried to make this a discussion—though obviously a one-way discussion. I tried to anticipate questions and respond to concerns and issues that I’ve heard about in the consultation room over the years. Also, I wanted to put in the things that I’ve tried to teach young doctors, whether it is talking about St. John’s wort, or the public suspicion about this or that aspect of psychiatry. It is not intended to be “the facts and nothing but the facts.” It is intended to be a personal account from someone who has seen lots and lots of patients.

What I want to emphasize as someone who has seen 8,000 patients or so, is what we still don’t know. …How do we go get the information that we need? (because at least some of the things that we don’t know are knowable). There is a message here: however you do it, the word is research. We’ve got to find out the answers.

The number of people with mood disorders is very high relative to the number treated. What more can be done in terms of educating people about depression?
That’s a very good question. There have been efforts at this in the past, but we need to do more in educating the educators of our patients. Those include the school system. I am thrilled and proud that DRADA has been involved in developing a curriculum on depression to teach in health class. The other health teachers for patients are doctors, nurses, psychologists, and social workers who traditionally have been educators and therapists and we need to beef up their curriculum. Educate the educators!

Now that you chair the psychiatry department in one of the most prestigious universities of medicine, what would you say is the future of American psychiatry, and your role in its development?
I think that the present in psychiatry is exciting in that we see an emerging consensus about a number of disorders. Over the last 20 years or so, people have been more coherent in their teaching about the most severe mental disorders, i.e., depression, bipolar disorder, schizophrenia, obsessive-compulsive disorder, autism in children, etc. There is an understanding of them mostly as diseases caused by genetic and nongenetic contributors. But also, we still are faced with the difficulties of psychiatry dating back to the ‘40s, ‘50s, ‘60s and ‘70s, and now they have the added 1990s—2000 twist of managed care. Psychiatric care, for patients and the doctors, is more economically disadvantaged now than it was in the 1950s and 1960s. Though two-thirds of people have some form of insurance, even the insurance doesn’t cover psychiatry in the way it used to.

The thing I’m looking forward to is when we are able to validate or prove this disease idea for these disorders and say, “Here is the brain abnormality you will see every time someone has a clinical depression,” whether someone got this from a stroke or from a genetic predisposition. If we can show the pathway in the brain that leads to manic-depressive illness or depression then I think we will be ‘relicensed’ as doctors to offer care in the way that we think we should. That will give support to patients and to the profession in terms of reimbursing the care and then we will judge treatments as effective or ineffective like we do in any other field of medicine. There will be a more level playing field with other diseases. It is also important because we will have much better ways to diagnose these disorders and we will hopefully develop more powerful forms of treatment.

Also, I am delighted to lead our efforts as educators—both to train young people in psychiatry and to teach them their special role as educators with families and patients. I get very excited thinking about that because I think in the next 15 years we will be able to make key breakthroughs for several major illnesses in psychiatry though I can’t tell you where the breakthroughs will be.

What is the future of the management of mood disorders?
In terms of the overall management—I’m glad to hear you use the word “management,” because our job as doctors is to manage all of the impacts of a disorder on the person’s life—as a package. That does not limit it to specific treatments of the symptoms. It is everywhere that this condition affects the person, we should be cognizant of that and have a plan that incorporates, to the extent that it can, all of the impacts. If it is affecting the person’s education, intervene with the family, the school—this is just as important as the medications and psychotherapy that you are doing. It is a truly comprehensive thing. The future of this is that hopefully we will get broader about our discussion. For example, because it takes 10 or more years to get the diagnosis made, what can we do in the meantime? It seems to me we can educate the higher-risk families about what to be aware of. The typical age of onset is 17 or 18 years of age; ask the doctor, “What is the impact of that?” The age range of 17 to 27 (onset to diagnosis) is big—so many things happen during that time that contribute to successful adjustment as adults.

Where is the latest research involved in the genetics of mood disorders?
We are getting closer to the genes that cause depression and bipolar disorder. We are at the place where we have strong evidence that there are multiple genes related to these disorders, but we haven’t yet isolated the genes.

What is your prediction of milestones–for next year?– for 20 years?
I have been taught by experience not to give specifics on that . . . .In 1990 Dr. James Watson answered very clearly that in two to three years we’ll have one or two or more of the genes for bipolar disorder and schizophrenia—and here we are 10 or 12 years later without any of those in hand for sure. I certainly believe that it will happen and that it will happen over the next 15 years. Honestly though, with the substantial resources that we have devoted to it, there is no reason that it shouldn’t happen in two or three years if we can find at least some of the genes . . .If we can find two or three or four of the genes for this disorder, we will make a clear breakthrough in understanding the pathway to depression or bipolar disorder. In Alzheimer’s disease, the first gene was found in about 1987 (the amyloid precursor protein gene) and then a second and a third gene were found. Then we could look at these three genes and see that one gene was found in this set of families, another gene in another set of families, and another gene was found by looking across the rest of the chromosomes for a look-alike gene compared to the second one. So that these three genes, though found in very different families, in the metabolic pathway of the brain, they line up–1,2,3.

Any final thoughts that you would like to add?
The only thing we could add is that we now know, due to the World Health Organization (W.H.O.) global- burden-of-disease studies, that this disease is worldwide. It is even less well-addressed in other countries than it is here. I do think we have to have an eye to the whole world and to all the people that are suffering from this. The W.H.O. estimates that this will be the number-two disease in terms of causing social, economic and other burdens—to societies as of the year 2020, worldwide. Currently, our vision of how to manage depression is really only applicable to the relatively well-to-do countries. That’s something that needs to change also.

Interview conducted by Wendy Resnick,R.N., M.S., Director, DRADA Support Services Program

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