Major Depression: An Interview with Dr. Eric M. Plakun

Dr. Plakun, how would you describe major depression?
To start, I think we need to distinguish the clinical entity of depression from sadness or grief — from ordinary life experiences. When we’re talking about depression clinically, we’re talking usually about a particular syndrome described in the Diagnostic and Statistical Manual of Mental Disorders, the DSM-IV, where there are biological correlates found in serious depression: things like sleep disturbance, appetite disturbance, disturbance in sexual functioning, loss of pleasure, impaired concentration and suicidal ideation. And it lasts for a period of time. It’s not a bad day, but something that goes on for weeks or more.

Also, one of the things that distinguishes major depression is a pernicious sense of guilt or worthlessness. It’s not just, “I lost someone I love,” but this sense of having done something wrong, feeling worthless or humiliated in the loss. Grief can tip into depression, in a syndrome known as complicated bereavement, but then it’s a different animal.

Depression isn’t ordinary. But at the same time, isn’t it pervasive?
Yes, depression is extraordinarily common. It accounts for a huge amount of lost time at work, impairment of quality of life, and it often leads to death, because it’s significantly associated with risk of suicide. You can see from World Health Organization statistics that this illness burden is massive and growing. According to the WHO, depression was the fourth leading cause of disability in 2000 and is projected to be the second leading cause of disability by 2020.

With so many vaunted treatments for depression, how could it be growing?
That’s a good question. One reason may be better diagnosis. Another may be a fading of stigma, with people who are suffering bringing themselves to clinicians more than in years past. One thing that interests me, though, is the growing evidence about the limits of many of our treatments for depression. Even though there are really good treatments for depression that you can demonstrate are efficacious in the scientific statistical language, they all have a significant failure rate. Between 15 and 50 percent of people who get treatment for depression don’t get better. Only a minority recover fully. And even for those who do get better, we should be careful with the good news. For instance, studies show a significant number of people respond well to medications. But you want to be circumspect about these data, because there are really some troubling things about them.

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