A useful way of thinking of these issues is to consider the situation of a person who has allowed themselves to become generally unfit by not taking sufficient exercise, and who then falls and breaks their leg. Were they to go to a gymnasium and request to be placed on a suitable graded exercise program to restore their overall levels of physical fitness any responsible gymnasium proprietor would clearly send them to a doctor to have their broken leg healed before offering them such an exercise program, both to protect himself against the probability of future legal action and because he would recognise the person would be literally unable to carry out the exercise program even if he were foolish enough to co-operate with their unreasonable request.

There is therefore a strong argument to support the view that true depression, as defined and described above, is essentially a physical illness, and can therefore only be effectively treated with a modern antidepressant drug, however lesser degrees of apparent depression have been shown to respond to a particular form of modern psychotherapy, the difficulty in this case being that there exists a continuing degree of uncertainty as to the exact balance between unhappiness and true depression where the patient is not manifestly and gravely depressed. It is reasonable to argue that, in the presence of a lesser degree of depression, the damage to the mood mechanism is not so severe, and it is therefore possible for the individual to be both to a degree depressed but also to experience normal mood responses to the environment.

Herein lies the core problem which continues to exist in the diagnosis of depression, although there is little argument these days regardless of what differences of opinion may exist in terms of the management of lesser degrees of apparent depression, as to the essential physical nature of depression, that opinion and knowledge has not given rise to a reliable diagnostic test that can be carried out in a living human being, and therefore the diagnosis of depression continues to be based upon the opinion of the diagnosing psychiatrist who, unlike his colleagues in general medicine, cannot then proceed to support, confirm, or reject his opinion on the basis of the extensive use of modern technology in the form of x-rays, CAT scans, and a vast range of blood tests.

If a patient presents to a doctor today complaining of generalised tiredness, and if the doctor comes to the clinical opinion that that patient is suffering from anemia, then the process from thereon is simple, reliable, and in general completely effective. The doctor takes some blood from the patient and sends it to the laboratory, where the laboratory either confirms or rejects his clinical diagnosis of anemia. If the diagnosis is wrong the doctor can reconsider his situation, if right the laboratory then tells him not only exactly how anemic the patient is, but the exact cause of that patient's anemia and therefore exactly how he can treat the patient effectively. Unfortunately none of these facilities are available to psychiatrists and their patients, and the management of depression with antidepressant drugs is therefore in the final analysis an exercise in intelligent and controlled trial and error. Effectively the treatment of each patient becomes an experiment in its own right, the doctor advancing a hypothesis that a certain drug will be most beneficial for this patient, and then testing that hypothesis by treating the patient.

Whilst this is not an ideal situation, and may at times give rise to cries of protest from those who do not understand the full difficulties involved, it is nevertheless a reality, and, if followed through logically and appropriately, will in the vast majority of cases lead to an acceptable outcome, that is the near total or total control of the patient's symptoms at the price of side effects, which if they exist at all, are minimal and fully acceptable to the patient as a price for the control of their depression. It cannot be emphasized too strongly that antidepressant drugs only control the symptoms of depression, they do not cure it, and that therefore to continue to prescribe or take an antidepressant drug, after a fair trial of the balance it offers between benefits and disadvantages, is a totally illogical process if the patient does not feel both better on than off the drug.

Perhaps one of the most misunderstood aspects of modern medicine is the nature of the side effects that are created by many modern drugs. In contrast to a toxic, or poisonous, effect, which is an effect that any individual will experience if they absorb more than a certain amount of a particular drug, side effects are defined as the unwanted results that arise from the use of drugs in some patients, on some occasions, and at some doses, and are not therefore a necessary effect of the use of a particular drug. However it is true that very few drugs serve any useful purpose whatsoever without producing side effects in these terms, that is unwanted consequences in some of the people who use them on some of the occasions they are used. The experiencing of side effects with modern medication therefore is by no means a necessary or universal event, and in fact the vast majority of people using modern medication do so either without side effects, or with side effects only at a level which they themselves regard as totally acceptable for the benefits they are gaining from the drug.

It follows therefore that the level of side effects, both in their intensity and frequency, which are acceptable from a given drug will be determined by the gain which is hoped for from the use of that drug. Those relatively few drugs which actually are capable of producing a genuine cure therefore may possess quite severe side effects, in fact side effects which are so frequent in the patients as to be closer to the definition of the toxic effects above, and yet be acceptable, an example of course being the very severe side effects of the drugs used in the chemotherapy of cancer and leukemia like illnesses. In this situation it is as always necessary to consider the balance of costs and benefits, most people would agree that an extreme, if temporary, level of discomfort is entirely acceptable to produce a permanent remission of leukemia in a child or young person, although many might question whether the use of extensive chemotherapy is always justifiable and reasonable simply to prolong life in an inevitably terminal illness in later years. In the context of the use of antidepressant drugs the balance of side effects and benefits which is acceptable however is determined by the patient's experience as the drugs themselves are not curative, but simply control symptoms, the best outcome therefore for the patient is the maximum control of symptoms with the minimum level of side effects that can be achieved.

In general it is not useful to be provided with an exhaustive list of possible side effects from each particular drug, not because of any danger of this leading the patient to imagine they have those side effects, but simply because any unwanted circumstances that arises whilst taking the drug may be a side effect of that drug, and preconceived notions as to the side effects which can be expected from a given drug may lead to a failure in adequate communication between doctor and patient about the possibility that the patient is in fact suffering from a side effect. However it is probably useful to know the most common reasons why people feel forced to discontinue a particular drug, and these issues can always be discussed between the patient and their doctor before treatment is started.

In the use of antidepressant drugs there is usually a delay between starting the drug and the onset beneficial effects on the patient's symptom of between approximately seven days and approximately eight weeks according to the individual drug and its interaction with the individual patient, and during this time it is not infrequent for the patient to feel slightly less well, being perhaps somewhat tired, dry in the mouth and with some, but not all medications, slightly nauseous. However providing these symptoms are minimal, it is worth persisting with the drug as the side effects frequently clear up as the beneficial effects of the drug develop. It is important that this particular probability is understood by the patient, otherwise, since most patients are also sensible human beings, they may well discontinue the drug in disgust before experiencing what could well have been very considerable benefits, and thus be condemned to continue with an unnecessary degree of suffering. However, if the drugs are started in a relatively low dose in the hopes of avoiding such side effects to develop, and persist, as the sought for improvement does not occur on the lower dosage level, thus leaving the patient with all the disadvantages of the drug and none of the benefits, a trap which can be avoided simply by an appropriate increase in dosage to a truly effective level.

To sum up, true depression is a totally different experience to unhappiness. Unhappiness, is a normal lowering of the mood which is an appropriate response to the external world, and should not be treated, formally or informally, with drugs, whereas true depression is an abnormal lowering of the mood, which arises as a result of chemical changes in the brain, and therefore can legitimately be seen as effectively a physical illness, although one which produces psychiatric symptoms, which therefore requires physical treatment with modern antidepressant drugs.

Unfortunately however there are no effective tests to demonstrate the existence of this illness in a living human being, and therefore the distinction between unhappiness and depression in any one individual has to be made on a purely clinical level, that is on the basis of the doctor's understanding of the outcome of their examination of the patient and their taking of the patient's history. As a result there is a varying level of difficulty in diagnosing depression in any one individual. In general the more severe the depression, and the more complete the absence from that person's life of any apparent external stresses, the easier is the diagnosis. Conversely the lower the level of depression, and the more that patient's life has been effected by external stresses, the more difficult is the distinction.

Ultimately the only truly significant test is the patient's response to antidepressant medication. Antidepressant drugs do not relieve ordinary distress, unhappiness, and anxiety, a fact demonstrated by the fact, in contrast to many other drugs, including the minor tranquillisers, they cannot be sold on the streets. Therefore a clear improvement of the patient's symptoms, particularly when it comes on after an appropriate time lag trom the starting of the medication, can be taken as an effective confirmation of the diagnosis. In order to find the right drug, or combination of drugs, for any one patient, it may be necessary for both patient and doctor to patiently try a whole sequence of different medications and establish which drug, or combination of drugs, is going to be of the most benefit to the individual patient concerned.

The principle underlying this trial and error process will be, as described above, a search for the most complete level of symptom control in association with the minimum possible level of side effects. However, providing both patient and doctor are sufficiently patient and systematic in their approach to the problem, for the vast majority of people who are truly depressed it is possible to achieve, either in the short or medium term, a near complete control of their symptoms allowing a return to their normal quality of life, with a minimal, and usually insignificant, level of side effects.

The drugs however do not cure the illness, and there is no evidence to suggest that they shorten the natural duration of any given depressive illness. It will therefore be necessary for the patient to continue on the level of medication which fully controls their symptoms until such time as the depressive illness passes naturally, a period of time which may be anything from a few months to the rest of the patients life. As a general principle as long as there is any evidence, in the terms of even the most minimal symptoms, to suggest that the depressive illness is still active it is unwise to reduce the level of medication, as to do so will almost certainly only lead to an unnecessary re-emergence of the symptoms, with an adverse effect on the patient's quality of life.

However, providing the patient has been apparently in every way as well as they were before the development of the illness for a significant period of time, and twelve months is perhaps a reasonable, if arbitrary, period in this context, it is reasonable to reduce the medication in order to test the hypothesis that it is no longer required.

In general it is undesirable to stop the medication abruptly, not because of the dangers of withdrawal effects, which are very rare, although not entirely unknown, with this class of drugs, but simply because to test the proposition that the drug is no longer required by an abrupt discontinuation means that, in the event that the drugs are required, this will be demonstrated by the patient lapsing back into as severe a level of depression as they were experiencing prior to the symptoms being controlled by the drug, which in some case may involve the risk of suicide, a phenomenon which, if it occurs, is unfortunately irreversible.

The principle therefore is to reduce the medication slowly, with each step being of the order of twenty- five percent of the total dose where that is in the higher range or fifty percent of the total dose where the total dose is in the lower range of dosage levels, with each reduction taking place only after a three month interval, during which there is no evidence whatsoever of any deterioration in the patient's condition. In the event of any such deterioration then the dose of medication should be returned to the original effective level, and maintained at that level for a reasonable period of time, as constant repeated trials simply prove to be disruptive to the patient's lifestyle and of no particular benefit to their overall wellbeing. Again a valuable general principle is that where a patient relapses into depression after having been effectively treated previously, the same drug which was effective in the previous episode should be used rather than entering into a search for some new and magic panacea that is most freshly off the shelves of the pharmaceutical companies.

A final word of encouragement, providing depression is understood and treated on the principles set out above it is today one of the most effectively treatable psychiatric illnesses, and indeed is perhaps in many ways more treatable than a wide range of illnesses that are more commonly recognised as being physical in their nature and requiring physical treatment.

Suggested further reading:
"Depression, Lifting the Cloud", Dr Christine Read Health Books, 427/150 Queen Street, Woolahra, New South Wales 2025 Telephone: (02) 9361 5244

But for "normal depression" read "unhappiness" - and for "depression" in the context of grief read "Sorrow"

Article contributed by: Dr. Chris Percival, Psychiatrist, Shepparton, Victoria, Australia.

Milton Sofoulis Sr, Dip.B.S., Dip.Min(Hon), Dip. Prof.Couns., is a professional counsellor based in Deniliquin, NSW, who specialises in relationship counselling, stress management, self esteem, and for general personal issues.

He is available for personal counselling, group counselling, interactive discussion groups, corporate presentations, and presentations for special interest groups.

Phone/Fax: (03) 5881 2581. Mobile: 0438 812 581. .