How To Overcome Depression (translated) 4h3i4q

INDEX

PART ONE - UNDERSTANDING DEPRESSION

I. WHAT IS DEPRESSION?

II. SERIOUSNESS OF DEPRESSION

III. WHAT YOU SHOULD KNOW ABOUT ENDOGENOUS DEPRESSION

IV. WHAT YOU SHOULD KNOW ABOUT REACTIVE DEPRESSION: PAIN

V. WHAT YOU SHOULD KNOW ABOUT NEUROTIC DEPRESSIONS

VI. A TABLE: THE KEY TO UNDERSTANDING DIFFERENT TYPES OF DEPRESSION

VII. GENERAL SYMPTOMS: WHAT TO DO

VIII. SLOWED-DOWN SYMPTOMS. WHAT CAN BE DONE ABOUT IT

IX. DELUSIONAL SYMPTOMS AND WHAT TO DO ABOUT THEM

PART TWO - OVERCOMING DEPRESSION

X. PHARMACOTHERAPY

XI. YOUR ROLE IN PHARMACOTHERAPY

XII. PSYCHOTHERAPY

XIII. YOUR ROLE IN PSYCHOTHERAPY

XIV. TREATMENT: WHO CAN CURE?

CONCLUSION

Dr. Leonard Cammer

How to overcome depression

Translation and 2021 edition by Planet Editions

All rights reserved

PART ONE - UNDERSTANDING DEPRESSION

I. WHAT IS DEPRESSION?

Perhaps you are reading this book because one of your family has entered a crisis. It could be your mother, sister, uncle, or any of the family , and you may have been wondering for weeks or months what was wrong. I am sure that you have also been trying to bring this person out of his or her despondent state, suggesting walks or film shows, and begging friends to come and visit, to see if they could cheer him or her up a little.

But you see no results. Your family member is always far away from everything and everyone, and as you watch him, immersed in his deep melancholy, you get the feeling that life has come to a dead end for him. You that once the sister of a friend of yours went through a period of this kind; you did not pay much attention to it then, but now that it touches you more closely you are bewildered by it, and begin to wonder what could be the cause of such a condition. It may even be that, if you are like many people I have had occasion to meet, you begin to think that you are the cause of that particular state of mind, that in some way you are to blame.

"What is happening to us?"

Discontent enters your home. The opinions of family are divided. Everyone has a say in what should or should not be done, and arguments and quarrels ensue. If there are children in the family, they feel the general uneasiness and become capricious and intractable. In short, what you are witnessing is the process of disintegration a family can go through when one of its falls victim to a state of depression and there is no one to decide on a clear course of action.

At this point you may feel shaken and confused. How long is this going to last? And what is really wrong?

Your family member is suffering from depression

Yes, ill. For depression is not a mysterious intrusion of gods or demons, as many once believed. It is a disease, just like a heart or lung disorder, or any of the diseases you can think of.

Paradoxically, however, this can be a reason for optimism. As long as it is an insoluble conundrum, you can only derive frustration. Once it becomes a precisely definable disease, it can be dealt with as such. It may seem a depressing prospect ('a thing in the head' may have been your first distressing association), but please believe that it is by no means the end of the world. Most depressed people recover, because it is a disorder that can be treated with a very good chance of success. However, this is on one condition: that the help of the family is an integral part of the healing process.

Depression is not a product of modern times

This illness has been known to mankind since the beginning of written history. In the Bible, there are frequent descriptions of people distraught with grief, or of the anguished feelings of those who have lost faith in God and in themselves, and have lost all hope for the future.

In the fourth century BC, Hippocrates, the father of medicine, described four types of human temperament, one of which was the melancholic (depressed)

character. The term melancholia is still used to characterise the depressed person's condition of despondency and mistrust.

Depression was also a known phenomenon in the Middle Ages, although, as in antiquity, it was attributed to the negative influence of some evil force. It was only towards the end of the 18th century that more extensive studies in institutions and hospitals specialising in the treatment of mental disorders revealed the medical nature of mental disorders.

Today we can attribute depression to the sum of the effects of certain biological and social factors which, in a complex context, adversely affect the functions of the individual nervous system. The depressive effect on the individual's activities in turn changes behaviour, feelings and mental processes. The totality of these dysfunctions gives the picture of the disease we call depression.

Depression strikes without regard

If you are told, for example, that your brother-in-law suffers from depression, don't rush to say: 'Oh, no, not Giovanni. He is too intelligent. He couldn't let himself go like that. Or, if it is your Aunt Giovanna, whom you adore: "Impossible. She's always so cheerful, in such a good mood. She wouldn't let herself be depressed by anything".

This is absolutely not true. Depression can affect anyone - a housewife, a taxi driver, a businessman, a teacher, a gambler, an actress, a bricklayer, a shop assistant, a university student, a longshoreman, and so on. It appears in balanced adults as well as in neurotics and children. It can strike at every level of the economic, intellectual and social ladder, and in every personality type. One cannot simply close one's eyes to a phenomenon of this magnitude.

There are various types of depression, which I will discuss in the chapters to come, case by case. I would like to limit myself here to briefly outlining their general characteristics in order to facilitate the reader's understanding of certain ages.

Depression starts with a bad mood

In the introductory paragraphs I mentioned the occasional periods of bad mood that we all go through from time to time. But when these periods last and you can't get over them, and if your everyday life begins to be affected, they can lead to depression proper.

If the period of bad mood is prolonged

The sadness that pervades the person may already constitute the core of depression. The person in this condition becomes aware of his or her feelings, and may ask in despair: 'Why do I have to feel so bad?

Even when the depressed person is not aware of the particular quality of his or her emotional situation, he or she still feels that something is wrong, something is pulling him or her down. And it can be expressed more or less like this: 'I feel tired, heavy'.

The feeling of heaviness means exhaustion, exhaustion. People in this state can spend their days dragging themselves from one place to another, wondering how they can get out of it. If the depressive state is more advanced, he may even

refrain from moving at all. It is easy to notice his indolence, because the slightest obstacle becomes insurmountable in his eyes. His thinking faculties seem to be dulled, and his conversation has sudden gaps, absences. At the same time he may continue to complain: 'I feel restless, nervous'.

The mental suffering of depression

It is a psychic state with a very special emotional quality, a mixture of anguish, despair, self-loathing and intense feelings of guilt mixed with anger and fear. This mental pain can also manifest itself as agitation and despair. The sufferer claims that he or she never wanted to be born, or that he or she would like to escape existence.

The physical state of depression

Depression is accompanied by numerous physical reactions, but in almost all cases these are functional impairments (see Chapter VII for an extensive discussion of this term). Your family member may complain of discomfort and pain in the bones or ts, feelings of nausea and dizziness, heartburn, feelings of pressure on the head, or various other physical symptoms that do not, however, appear to be related to an illness on physical examination. Nevertheless, there is something wrong with his physical state, even if it is not something that X-rays can reveal, as depression as an active disturbance of nerve functions can give rise to physical symptoms.

In other words, the nervous system, which is a physical system and part of the body, may experience certain difficulties in functioning. Neural circuits are disturbed and inhibited because brain chemistry does not take place with the balance required for a harmonious emotional process.

Whether depression, however, is understood as a physical disorder or an emotional disorder is a purely academic question. From a technical point of view, one or the other or both may be true. The most important thing is that in each case there is a tendency to think of depression as a nervous condition, particularly in the expression 'nervous breakdown'. Have you not found yourself repeating these very words?

DEPRESSION AND NERVOUS EXHAUSTION

Allow me here an analogy. When someone says 'I've caught a virus', the meaning of this expression can range from the common cold to sinusitis to an attack of diarrhoea. Similarly, the colloquial 'nervous breakdown' can mean any kind of negative emotional experience.

One of my patients described to me the mild depression that followed the breakup of her engagement as "a terrible nervous breakdown". Another patient, who had gone through a severe (though short-lived) psychotic depression accompanied by collapses, spoke of it as "a slight nervous breakdown... nothing serious".

What I think I can say is that when people generally talk about 'nervous breakdown' what they are really referring to is an emotional disturbance that is so serious that it gets in the way of normal work and everyday life. In this respect, the definition is correct. Depression that distracts a person from his or her responsibilities can certainly be referred to as a nervous breakdown. But this term is still too vague, too general, to be of any use. What I would like to do, however, is to suggest a better method of understanding what happens in nervous breakdown which finds its final outlet in the depressive state. First, therefore, I will describe the functioning of the nervous (or tensional) energy system.

Tensional (nervous) energy in depression

Each of us moves, thinks, works, feels and so on, thanks to the constant influx of energy that the body can provide as a result of assimilating food.

In this case it is caloric energy, produced by the muscles.

But before this can happen, the brain and the nervous system, in coordination with the various glandular secretions and other chemical processes, must activate the muscles by means of tension energy.

It is a process that can be compared to the operation of a car engine. The calorific fuel in this case is petrol, but it is an electrical system consisting of a generator, spark plugs and distributor that provides the controlled energy that ignites the fuel. These two systems must work in close coordination.

At each successive moment of our day we discharge (consume) a certain amount of tensional energy. This is a normal fact. None of us could function as an organism in the absence of tensional energy, or even following a drop in this energy below a certain level, which can vary from individual to individual. If we want to move forward we must have, so to speak, a well warmed-up engine and the gear engaged. The crux of the matter with regard to tensional energy is therefore: how much of it do we produce, and how do we use it?

Some people produce and distribute their daily quota of energy wisely, thus managing to perform all their tasks. These people arrive at the end of a normal

day with a reasonable level of tiredness.

On the other hand, one may be faced with the case of a person who produces a normal amount of tensional energy, but discharges it excessively, and thus exhausts it too quickly.

In another case, a person with a normal tension threshold may find himself in a situation of prolonged stress: the bitterness (so to speak) of the 'struggle for survival' wears him down and oppresses him more and more; in this way he consumes increasing amounts of tension energy to sustain the competitive situation, and the result is a state of chronic fatigue.

In yet another case, the person may produce an excessive amount of tensional energy without being able to discharge it adequately. At first a whole series of psychosomatic symptoms may appear; but later, in trying to cope with the symptoms, they too will reach exhaustion.

In the course of days, weeks, or months these people will dissipate everincreasing amounts of tension energy, either by the excessive or uncontrolled expenditure of their emotions; or, conversely, by accumulating these emotions within themselves, only to see them transformed into physical ailments. Eventually every reserve of emotional strength will dry up; or, in other words, following the definition I gave in another book, a depletion of adaptive energy will occur.

We all need this particular type of energy in order to adapt to the various situations that life presents us with at each successive moment. If the individual loses or exhausts his or her ability to adapt, a depressive state results. (See Chapter V for a further discussion of adaptive energy).

Depression, therefore, indicates a failure of the entire individual being to adapt to the stresses of life. This does not mean that the person affected should be blamed for it. Rather, we say that his or her system for transforming tensional energy is no longer able to function as it should, and that the result of this is depression. The machine is worn out, exhausted; from this follows 'nervous exhaustion'.

CORRELATION BETWEEN ANXIETY, FEAR AND ANGER

If you try to understand depression in its deepest sense, the underlying cause of your family member's disorder is a nervous imbalance.

However, this illness can be related to three other components, namely reactions of anxiety, fear and anger. In most cases, there is a tendency to cover these emotional reactions with depression, and to use the term 'nervousness' or 'excessive tension' to describe all these unpleasant feelings. Example. A woman comes to me for counselling, and at first she doesn't say anything like: 'doctor, I am depressed'. Instead, her description will be: 'I am so nervous, I am afraid to go out alone' (fear). "The idea of coming here worried me. I had to have my son bring me because I was upset" (anxiety). "The smallest things make me afraid" (anxiety and fear again). "And when I am in this state I get angry, and I take it out on others too" (anger).

The son confirms his words. When these statements are finally confronted and analysed, what becomes clear is the depressive state underlying such emotional reactions and the related depletion of the adaptation reserves.

In order to recognise and understand depression, it is essential that you are not

led astray by the emotions linked to it. That is why you need to know the role they play, both under normal conditions and when they are overused.

Anxiety, fear and anger under normal conditions

In general, the emotions produced by the nervous system are an entirely normal fact that has its own specific usefulness. Each has the specific task of protecting us in certain stressful conditions, thus ensuring our survival. Thus, when some threat is brought to our life or safety, one of these emotions is mobilised in order to push us to act in directions that will allow us to escape the threat.

Anxiety, under normal conditions, mobilises us to make decisions and take a constructive course of action. A person, for example, feels anxious about his job, and anticipates the possibility of dismissal. The normal reaction is for this person to respond to the anxiety by taking some work home, studying the problems in the field, or trying to increase his skills and abilities. Anxiety thus helps him to secure his job.

Fear also has its uses. It causes us to retreat until the danger has ed. A person may be afraid to drive a car in heavy traffic if he thinks he might panic and lose control. He will therefore avoid busy arteries until he is sufficiently familiar with his vehicle. Fear can also prevent a person from acting impulsively in areas where he feels immature or lacks adequate knowledge. In this way he will gain time, and be able to accumulate more experience.

Anger is also a protective factor. There are many situations in life in which we find that we have to fight for our rights and our safety. Anger sharpens our senses for this purpose. A soldier may not realise that the real reason for his hatred of the enemy lies in a biological mechanism that enables him to cope effectively with the dangerous situation, but that is exactly what it is about:

anger merely mobilises his adaptive energy for self-preservation.

However, one can overreact

In fact, it may be that we develop too much anxiety, too many fears, and that the anger we feel in certain situations clearly oversteps the mark. This happens when the person can no longer cope with the threats that seem to be hanging over them.

An illness - of any kind - is indeed a threat. If this illness is depression, the individual will react as to any other illness with anxiety, fear and anger that often grow to uncontrollable proportions.

How anxiety, fear and anger manifest themselves in depression

Anxiety manifests itself in the form of restlessness and panic attacks. The person always tends to expect the worst, feels nervous and uneasy about the slightest event. He or she is always on tenterhooks, and the physical symptoms of anxiety such as sweaty palms, headaches, palpitations, etc. also appear.

Fear is manifested by the person's refusal to be alone, and at the same time by his withdrawal into himself when he is among people. Fears of failure are also expressed. "I should quit my job, they will fire me anyway", or "I'd better give up that business. I'll never get it done".

Anger is expressed as rage against the disease. The person expresses self-

destructive intentions: he/she would like to slap him/herself, hurt him/herself. He has frequent outbursts of anger, during which he directs his sarcasm (and sometimes even physical attacks) at anyone in range. She may even decide that "they" are part of a conspiracy to persecute and destroy her, and that they are plotting to do so.

It is of paramount importance that you do not get sidetracked by such manifestations of anxiety, fear and anger and conclude that your family member is perhaps throwing a tantrum or playing the 'prima donna'. I am not saying that this can be as easy a task for you as identifying items one, two and three on the shopping list. These are subtle and deceptive symptoms. But if you look closely you will eventually uncover the depression that lies beneath, especially when you realise that despite the unpleasant and moody aspects of this person's behaviour they are sad, exhausted and inert, they berate and despise themselves, and they communicate less and less with the world around them.

THE FEAR OF MENTAL ILLNESS

When someone is depressed, it is not only feelings that are distorted, but also thought processes. He may toy with the idea of downing a bottle of barbiturates or throwing himself out of a window. Or he may brood day and night over irrelevant problems that 'won't go away'. The person realises that the persistence of such thoughts is not natural. He will meditate on this fact, perhaps alone and in the dark, and eventually come to what seems to be the only logical conclusion: "I am certainly going mad". Her conclusions about madness do not yet have the character of certainty, because she realises that she always knows who she is, what time it is, where she is, and who the people around her are. But what remains is the fear that her crazy thoughts may eventually lead her to mental illness.

Don't expect your family member to express all that

He may appear very uncommunicative, but that is not the point. He is simply afraid to express the feeling of impending menace that pervades him, firstly because he thinks he will be mocked, or thought to be insane and committed to an asylum, and secondly because a certain superstitious fear suggests that if such thoughts are verbalised they will turn into real forces that will take hold of him and keep him in their control.

The ideas that torment him are also of another kind. "If I go mad, this disease will be ed on to my children. However unfounded such fears may be, they contribute to the guilt that develops with depression. This sets off a chain reaction - from depression to fear to guilt to deeper depression.

It is by no means true that a depressed person 'goes mad'. But the fear of such developments may in itself be a symptom of a depressive state.

DEPRESSION AND HEREDITY

When an illness affects a certain person, and the victim is unable to understand its nature, he or she may begin to wonder whether the illness is not due to hereditary factors. This is especially true with regard to emotional disorders, including depression, which have always appeared as the most threatening and mysterious disorders. There are many reasons for this. In the past, when little was known about the causes of diseases of emotional mechanisms, people linked them to heredity, and consequently to evil. The line of reasoning was more or less this: if a person was well and productive he must have inherited good qualities; if he was emotionally disturbed he must have inherited bad qualities. Mental illness was then put on a par with evil. And consequently the depressed person, powerless to recover from his condition, was stamped with the stigmata of wickedness, and every door was closed to him as wicked.

Since until relatively recently there was no treatment for this kind of disorder, the stigma could persist for a long time, so it is hardly surprising that when a person believed in an inherited and 'incurable' depressive illness and fell victim to it, he felt his fate was sealed, as did those around him.

Heredity and genetics

The beginnings of genetics as a science can be dated to the late nineteenth and early twentieth centuries. And it is only a few years ago that we began to explore the molecular structure of genes, which in turn determines the genetic code. It is this code that can provide us with accurate information about the inheritance of various traits and individual characteristics and predispositions of the human individual, as determined by the union of the egg with the sperm.

We thus know that a person can inherit a certain predisposition to disorders such as obesity, allergies, particular sensitivity to certain medicines, and so on. But it is by no means certain that such predispositions actually have to come about. Just because your mother, grandmother or aunt suffers from diabetes does not mean that you do. This is true for many other diseases, including depression. There is no evidence to suggest that depression can be directly ed on through inheritance. An ancestor may have suffered from it, but that does not mean that you have to. I say this because we now know that it is also possible to modify situations of hereditary predisposition. It is a fact that biologists have not yet been able to establish whether the hereditary heritage or the environment in which a person is born and grows up is more important for him or her. Studies in the field of genetics can ultimately only inform us about the 'clay' of which we are made. Pending further discoveries, if a person you know is particularly concerned that their depressive episodes may be ed on to their children, the only thing really advisable is a clarifying discussion with their doctor.

In the light of our current knowledge, however, we have no grounds for excessive concern about the heritability of depressive illness. The evidence we have seems to point rather to the possibility that the environment may more than compensate for a hereditary predisposition to depression, as well as to other illnesses. There are too many factors that can play into the integrity of the person today. Developments in science and social institutions are an essential protective factor that adds to the strengths of the individual constitution and helps stabilise biological functions against all kinds of disorders, whatever their predispositions. In addition, people are gradually learning to communicate their mental and emotional problems more openly to others. One of the results of this situation is that both public and private employers have come to recognise that depression is an illness that can affect anyone; and also to understand the need of the individual suffering from this illness to be relieved of the burden of excessive stress. Many employers are therefore willing to cooperate with therapeutic treatment by granting the sufferer periods of rest while keeping him or her in employment. This illness, therefore, no longer has to be kept as a secret to be ashamed of; it can be tackled and overcome without the burden of secrecy being added to the cure.

Psychosis is the scientific term for a serious mental disorder. The characteristic symptoms of psychosis are hallucinations, delusions and loss of with reality. To these can also be added a profound state of depression. But you should not be frightened by the word psychosis, or by the diagnosis of this disorder in one of your family . You may have heard that a person suffering from psychotic depression goes through a long period of hospitalisation. This may have been true twenty or thirty years ago, but not any more. Such an episode can be overcome by psychiatric treatment. It is worth ing that in the vast majority of cases, recovery occurs in a relatively short time, regardless of the intensity of the symptoms during the critical period.

II. SERIOUSNESS OF DEPRESSION

When I say that depression is serious, I do not mean that it is an irreversible disorder. The depressed person can recover. What I am saying is that you have to take depression very seriously, because people who experience depression can fall into such a state of suffering that they will resort to any means to alleviate the pain in their mind. They may, for example, attempt suicide; intoxicate themselves with alcohol; seek oblivion through drugs; retreat into a life of total isolation.

HOW TO RECOGNISE SUICIDAL TENDENCIES

I want to run the risk of being blunt, because many people have a tendency to shy away from the idea of such an eventuality, as if it might then become less real.

The percentage of cases of depressive illness that end in suicide is alarming. This is the most direct way I know of of of saying that depression can be a fatal disease. It can lead to death, even if it is a death that the person inflicts on himself. Every day we read in the newspapers about a housewife who seals her windows and kitchen door and turns on the gas, an actress who swallows a whole tube of sleeping pills, a businessman who hangs himself. And since depression affects children, adolescents, adults and the elderly alike, suicide also knows no age limits.

If you have even the slightest suspicion that your family member is in danger of destroying himself or herself, and is perhaps dangerously close to the fatal step, do not hesitate to act on your suspicions. You may be closer to the truth than you

think.

Unfortunately, there are many myths circulating about suicide that make the average person less ready to grasp its possibility. I will therefore try to enucleate the commonly circulating misinformation on the subject, and please take note of it as carefully as possible.

Mistakes and truths about suicide

ERROR: When a person threatens to commit suicide, does not talking about it exclude the real possibility of the act?

TRUTH: Not at all. The depressed person almost always 'invokes' protection either directly or more covertly, against what is an actual impulse. Out of ten people who attempt suicide, eight have forewarned others of their intention. "Talking about it" is the person's way of letting you know that suicide is imminent. There are many people who could be saved on a daily basis, if other people had been able to understand what they were trying to say. But if there is no one to pick up the message and if no one is able to offer help, suicide becomes a reality.

ERROR: But isn't it possible that the person who says he wants to commit suicide or harm himself is simply pretending? Isn't this a way of demanding attention and manipulating those around him?

TRUTH: Every depressed person demands the attention of others, and uses every psychological stratagem to satisfy this need. But if these stratagems are ignored or rejected, even if the person in question employs them to attract the

attention of others or to manipulate others, he may then be overcome with despair. By rejecting such a person, one is only challenging him to desperate actions. And these are by no means uncommon. When one has the gun to one's head and pulls the trigger, unfortunately there is no time to change one's mind.

ERROR: Isn't it true that when someone has attempted suicide once, they never try it again?

TRUTH: No. In this case the lightning may strike in the same place more than once. In many cases of suicide it turns out that there have been one or more failed attempts beforehand. And the second attempt often has a good chance of success.

ERROR: If a person has deep religious convictions he will not try to take his own life, will he? Suicide would be in contradiction with his faith....

TRUTH: Priests, pastors and rabbis suffering from depression have committed suicide. Faith or religious observance has never prevented a depressed person from self-destruction.

ERROR: When a person attempts suicide, does this not indicate signs of mental imbalance?

TRUTH: While almost all those who take their own lives can be described as depressed, this does not mean that they are psychotic or 'crazy'. The individual may be in perfect touch with reality, and at the same time feel unable to bear the burden of depression and the merciless mounting of tension any longer. Their judgement is distorted and life gradually loses its meaning and value. While

some people 'get it over with' on a sudden impulse, others are able to coldly devise a plan to find escape in death.

I certainly do not think I have exhausted all the false beliefs in circulation. But these are the facts, and this is the hard reality.

Number of suicide cases

In the United States, suicide ranks tenth as a cause of death for the entire population. Considering college students, it is second. For the group of adolescents (ages 15 to 19) it is third, and for young adults (ages 25 to 44) it is fourth.

Studies conducted by the US Department of Health, Education and Welfare on the subject reveal that more than 20,000 people die by their own hand every year - roughly one person every 20 minutes. Unofficial estimates indicate that at least as many people kill themselves each year, without their suicide being considered as such, because in our culture such an act is considered unfortunate, ungodly, or can cause problems in collecting life insurance policies. It is not unlikely that the actual number of deaths by suicide is between 40,000 and 50,000 per year.

Another thing to be aware of is that for every person who succeeds in killing himself there are five to ten who attempt the same act without success. Studies conducted in this regard tell us that in the United States there are about two million people who have made at least one suicide attempt. And it is not comforting to think that these two million people represent a reservoir from which numerous cases of successful suicide will surely emerge in the coming years.

The dryness of these numbers, as is always the case with statistics, will make them seem like something abstract, which has very little to do with your family member suffering from depression. But if you try to translate them into human values, you will begin to realise how many people could have been saved if only the warning signs of their intent had been recognised in time.

It is therefore good to state this basic rule, to be followed whenever dealing with a depressed person: Next to this person there should always be someone else, or, if this is not possible, other systems must be found to protect them.

What drives a person to suicide?

Any one of many dilemmas. You may not yet be aware of your family member's state of depression, but you can certainly discern his or her suicidal intentions if you keep the following conditions in mind, and can detect even one of them.

HAS THERE BEEN A RECENT LOSS? It may be a loved one, an object, an opportunity, as well as the intangible thing that is personal prestige. The loss can take on gigantic proportions for the person, and they may come to feel that they will never be able to recover. "How can I go on?" he complains, and secretly plans not to go on at all.

HAS THE INTENSITY OF THE STRESS CAUSED A STATE OF CHRONIC FATIGUE? Perhaps an uninterrupted series of misfortunes has prostrated this person, and the struggle to recover from them has taken its toll. Overwhelmed by physical, mental and moral exhaustion, she is no longer able to recover. The risk of suicide becomes more and more real.

IS LONELINESS AND A SENSE OF EXCLUSION EVIDENT? Your family member may manifest the emptiness that comes with a life of loneliness. It is obvious to him that there is no longer a place for him in the world, no one wants him, and only a fool would hope that this situation would change.

So why fight? Don't drop this as just an idle talk, because it may be his way of telling you that he is looking for death.

DOES THE PERSON IN QUESTION SEEM LOST, INSECURE? There may be no obvious signs of depression at all. But suddenly you feel uncertainty, doubt, an inability to move to a normal level of trust in yourself and others, a sense of total inability to perform any task. You must be cautious, and listen to him with extreme attention, because his words may reveal an overall plan how to find the courage to 'get it over with'.

HOW TO RECOGNISE A TENDENCY TOWARDS ALCOHOLISM

The torment of psychic suffering, as I tried to describe it to you in Chapter One, is relentless. The person is subjected to a kind of continuous guerrilla warfare, until at the centre of all his desires there is nothing left but liberation from that suffering.

Suppressing psychic suffering

The most common 'analgesic' for mental disorders is alcohol. The use of alcohol in this sense is hardly a recent discovery: it is not a natural substance, but every society has discovered a fermentation process to produce this type of narcotic. Almost universally used, it is the oldest of tranquillisers. The depressed person

can therefore quite logically turn to alcohol to find relief from his mental hell. The relief is effective, but hides a double danger:

FIRSTLY, ALCOHOL PROMOTES A DEPRESSIVE STATE. Although it reduces mental suffering, at the same time it contributes to depressing the nervous system. The overall effect therefore favours depressive illness.

SECONDLY, ALCOHOL CONCEALS. When the family comes to recognise alcoholism in one of its , it may miss the real disease (the depression that fostered the tendency to alcohol).

For example, I treated a 35-year-old housewife living on the outskirts of a large city who was showing symptoms of severe fatigue due to an excessive effort to control her family and her children's upbringing. He could no longer keep up with the amount of tasks he set himself on a daily basis, and the resulting tension had gradually developed into a depressive state. At one point she discovered that a drink or two before going to bed helped her to sleep, as this was also beginning to become a problem. Then she discovered that another one before dinner helped her to cook. Then she found that a few more drinks helped her overcome her evening jitters, and that two or three drinks during lunch calmed her nerves for the afternoon. Before six months had ed, she was drinking almost a bottle of spirits a day. But it would be another three or four months before her husband and children noticed that 'mum always has a glass in her hand'. Eventually she was taken to the family doctor. Alcoholism seemed to be the main problem here, but the psychiatric examination revealed a primary state of depression, for which she was successfully treated. She stopped drinking overnight and was able to return to her duties effectively.

Depression does not necessarily underlie every case of alcoholism. There are many causes that can drive a person to drink, but depression of any kind is one of the most important. When one of your family starts to treat themselves with alcohol, it is very likely that they are masking their depressive

state in this way. And if as a result of this there is a delay in proper diagnosis and treatment, it may be too late.

HOW TO RECOGNISE THE TENDENCY TOWARDS DRUG ADDICTION

What I have said about the risk of alcoholism can certainly be applied to the possibility of drug abuse. Virtually every kind of drug is available on the legal and illegal market today. The depressed person may often see two or three different doctors, hoping for a 'miracle cure' from each, and getting a prescription from each. In the end, the result is an overuse of psychotropic drugs: the person convinces himself that if one pill is good, two are better, and three or more are even better.

Self-care

When one of your family tells you that he/she is taking an 'exceptional medicine' ed on by a friend, you must exercise the utmost vigilance. He says, "It cheers me up, makes me feel great". What you have to ask yourself is: why does he need to feel good? And what's in those pills? Maybe you let it go, thinking it wouldn't last more than a day or two. But a few weeks go by and you find that he is still taking them, and in larger and larger doses. It could also be that you were asked for money to buy it on the black market. At this point you realise that something serious is going on.

Pill eaters

Among the medicines most frequently used by people suffering from depression

are sleeping pills. These are the most widely used and abused psychotropic drugs, since insomnia and restlessness are among the main symptoms of depression, and since the person feels tired and exhausted, he or she will also resort to stimulant drugs. Stimulants give a temporary shock, but at the same time induce a nervous reaction. It follows that at the same time as the stimulants, tranquillisers are also taken, which help to alleviate the situation of restlessness, which may itself have been aggravated by the use of stimulants. (See chapter X for an extensive discussion of this topic).

The tense and depressed person then becomes a 'pill eater'. Pushing down pills gives them a certain sense of security: tranquilisers and stimulants during the day, sleeping pills at night. But imagine the effect on the nervous system! Suppose we have an electric motor, and we run it alternately at a higher and lower voltage than it should normally operate at. How could we expect it to run smoothly? The motor would hiccup and eventually burn out. Similarly, when the balance of the nervous system is stressed in a similar way by the use of medicines, the latter will soon come to exhaustion, to the point of 'burning out', with the rapid appearance of the hitherto masked depressive state.

From depression to drugs

Once your family member has taken to self-medicating without the slightest external control over doses, he or she is already on the road to addiction. This is particularly true of opiates (heroin, morphine, codeine and similar narcotics), stimulants (amphetamines and others) and tranquillisers (barbiturates, sedatives and other psychotropic drugs).

I have treated a number of patients who present with severe sleeping pill and morphine (or other opiate) addiction due to an undiagnosed depressive state whose symptoms they have tried to alleviate. And apart from cases of true addiction, there are many who turn to LSD ('acid'), barbiturates, marijuana ('weed') and amphetamines ('speed') for similar reasons, just to 'cheer themselves

up'. If you find out that one of your family is taking these substances, a medical examination should be carried out to check their emotional balance. And don't be surprised to learn that very often an initial depressive state is at the root of the drug problem.

HOW TO RECOGNISE THE TENDENCY TOWARDS SOCIAL ISOLATION

It is in the very nature of depression to lead the individual into a state of isolation. The slowing down of physical and mental functions in this case simply makes communication with the social environment impossible.

Unfortunately, most families do not understand the deeper meaning of isolation. If they did, much pain and suffering could be avoided. In some cases the person with isolation tendencies is reprimanded or even ignored as a retaliatory measure. In more sensitive family situations, attempts will be made to persuade the person to take a more active part in social life. But in none of these cases will the aim be achieved, because depression is at the root of the problem and has not been identified.

If, for example, the person states that he/she just wants to be left alone, the family will be only too happy to leave him/her alone. At a later stage, however, the person will say that they are afraid to be alone, and that they need to be with someone else. You can try, but when you try to keep her company, the situation will be very unpleasant. She will sit there without saying a word, and no matter how much you try to tell her not to exclude yourself from her world, that you love her and want her to be happy, her reactions will be completely negative. In the end you will come to the conclusion that she is absolutely unattainable, and you will go back to your own affairs, silencing with some discomfort your scruples in this respect. How can your empathy be aroused?

Meaning of empathy

Empathy for depressive disorders is something you should try to cultivate. You may feel anxious about your family member: you feel sympathy, which means that you feel something for them. However, this is not the same as empathy. Empathy is a word used in psychiatry, meaning the ability to feel what the other person feels, and to understand that feeling - an emotional identification, the ability to put yourself in the other person's shoes.

For physical illnesses this is much easier: pneumonia or a heart condition is something you can 'feel' on your skin. Or, if the patient for example has a broken arm, you are able to 'see' his problem, you can touch the plaster holding the limb and 'feel' the discomfort of the fracture. Empathy is just that, and it is something that leads us to be solicitous and to care for the sick person.

But when one isolates oneself from all those around him or her because of a depression that no one understands, or even recognises, there is a strong temptation to wash one's hands of it. Worse, many may feel offended by the depressed person's lack of 'trust' in them. A mother told me, for example, in the presence of her son, who was the patient in this case: "He just keeps to himself, as if we didn't even exist. He knows that we love him. So why does he have to hurt us by behaving in this way? You don't know what I've been through, doctor." If only this mother had understood what he had been through and suffered!

When you avoid facing the problem

The depressed person realises that he is a burden on his family. But he also feels that he is a burden to himself, since he is incapable of resolving his condition, and this fact humiliates and shames him.

If the isolation is allowed to continue, depression can destroy many family relationships, such as between husband and wife, or between parent and child. What happens is that people generally refuse to accept what they cannot understand. Sooner or later the behaviour of the depressed person arouses the hostility of others, and a rift is created. Everyone turns away from the depressed person. Everyone minds their own business, and this increases the separation. When the isolation lasts too long, the mark left on family relationships is not so easily erased, even after the depression has ed. The person concerned and his or her family will always be on edge because of past antagonism.

That is why it is essential to understand that isolation is not a consequence of a deliberately perverse attitude of character, but a symptom of something else. I am tempted to say that if the average family could perceive it in the proper context and see the interplay of relationships underneath it, they would express this realisation more or less like this: 'No wonder he has distanced himself from us. He feels that he is a ball and chain for us, and understands that it is the same for us. It must be a really terrible thing. Let's see if we can find a way to help him out. We think we owe it to him.

III. WHAT YOU SHOULD KNOW ABOUT ENDOGENOUS DEPRESSION

For practical purposes I have found it very useful to divide depressive disorders into three main categories:

1. Endogenous depressions

2. Reactive depression

3. Neurotic depressions

In this chapter I intend to discuss the first category (the second and third will be discussed in the two chapters following this one). As a preliminary consideration, I would like to recall the three essential factors that can be identified in any type of depression: intensity, duration, and quality.

The intensity may vary. It may be mild, moderate or severe. As a general rule, mild depression, however distressing, can be overcome fairly quickly. Moderate or severe depression should almost always be considered a serious disorder and should lead to medical attention.

Duration. Depression can be acute, recurrent or chronic. Acute depression, for whatever reason, comes on quickly and can last from a week to four months. It

can be overcome spontaneously, without psychiatric treatment. Recurrent depression consists of acute episodes that reappear at successive intervals, interspersed with periods of normal emotional state (called 'remissions'). Chronic depression occurs more gradually and lasts for an indefinite period of time, up to two years or more, with final and definitive remission.

The quality of a depression can be: delayed - meaning that the person's functions are slowed down; or agitated, when the sufferer is in a state of general nervous excitement.

When studying the various types of depression that I will describe in the following pages, you will encounter the specific defined above. It is important to try to keep them well in mind, because they can be a valuable key to assessing the patient's condition.

ENDOGENOUS DEPRESSIONS

This word means 'internally generated'. Endogenous depression results from some kind of disorganisation of the brain and nervous system (parts of the inner person) that prevents normal functioning. Doctors may define this type of depression as a physical or organic disturbance of nerve function, and that is precisely how it is. The following paragraphs describe different types of endogenous depression.

Menopausal involutional melancholia (change in vital rhythms)

Perhaps you have come across a case of involutional melancholia in one of your family . And perhaps the first question you have asked yourself is: how

could something like this have happened to a member of my family? It may reassure you to know that, of all the types of depression, this is the most common, the most familiar to the doctor, and the one that responds best to treatment.

In women, the disorder appears between the ages of forty-five and fifty-five; in men, between sixty and seventy-five. Although involutional melancholia is a major disruptive factor in the family situation, especially if both parents are going through the menopause at the same time, it is rare for the family to seek medical help quickly enough or with the decisiveness that the disorder deserves. Given the excellent methods of treatment now available to us, the discomfort of the involutional period is something that can and should be avoided. It may be that many men and women, especially women, approach the menopause as the martyrdom period that was described by past tradition, as an implacable enemy from which there is no escape. But it is a fact that the symptoms can be alleviated, and above all the wear and tear caused by agitation and depression can be avoided.

The involutional depression of women

The person I would like to describe to you may possess traits familiar to you. It could be your wife, your mother, an aunt, or any of your female relatives.

Suppose that in recent months she has seemed more nervous than usual: the doctor has told you that she is going through the menopause. You wonder if this is the reason why she has been so irritable recently and is ready to snap at the drop of a hat. Everyone in the family starts to stay as far away from her as possible. She cries, wrings her hands, and constantly complains of her "nerves", of burning heat sensations in the back of her neck, and of a feeling of stiffness, "like a band around the head".

You wonder if this situation is not due to her moving from the old neighbourhood, where she lived for twenty years. She tells you that since then she has never felt comfortable in her old clothes. She hates the new house and the new neighbourhood, and says bitterly that she can no longer sleep here, even with the pills the doctor ordered. The old house didn't have all that noise from the street, and those people upstairs... (and you know that's not true, the old house was much louder). You also suspect that if the move is not to blame, something else is. Six months ago he might have blamed it on the death of his mother (in her old age). Or if a recently divorced daughter came to stay with her with her child, this could be the reason.

However, whatever the reason, you may notice a state of disturbance. This person may even have begun to harbour ideas of persecution, and to think that everyone is conspiring against them. You begin to realise that, apart from the menopause, something else is really wrong and that a solution must be found. To continue like this would be hell.

Man's involutional depression

When a man goes through the menopause, the physical symptoms that accompany it are far less obvious than those found in women. But if, as a result of these changes, involutional depression sets in, the symptoms of restlessness and depression will be much the same.

As a result of the disease both men and women tend to lose interest in any kind of sexual activity; but in the man there is often a shift in this loss of interest in the form of suspicions about his wife's fidelity. This is followed by checks on the latter's telephone calls and mail. After so many years of marriage, such jealousy reactions can confuse the most serene and devoted wife. And very often, for the sake of peace and quiet, friends are warned by her to stay away, and even to avoid phone calls.

The upheaval and despair of involutional melancholia can lead the person into such an abyss that, in extreme cases, he or she may find refuge in suicide.

What are the causes of involutional depression?

Let us first that the menopause could or should occur as a normal experience for each of us. And most people do not become depressed during this particular period of existence.

So why does this happen in some cases? No one knows for sure what it is that triggers the intense, agitated depression of the menopause. A great deal of clinical research seems to point to changes in the body's hormonal balance: this would be the mechanism that triggers the imbalance in the nervous system that in turn gives rise to depression. A rigid personality structure could also play a role. A 'perfectionist' individual, for example (who is unable to adapt to change or to compromise when necessary), might break down when faced with one too many stressors, just to avoid giving in. The hormonal changes of the menopause could be precisely this excess stressor, and as a result the individual can no longer maintain his stability. As the weeks go by, there is a gradual depletion of the reserves of nervous energy, and with successive failed attempts to adapt, involutional depression finds fertile ground, until the final nervous breakdown'. (See Chapter I, section on tension energy in depression; also Chapter V, section on depletion of adaptive energy).

Manic-depressive disorders

In my experience, manic-depressive illnesses are the most disconcerting for the families of those who fall victim to them.

Let us first consider the meaning of the word manic. It is precisely a psychiatric term that refers to the sense of 'intoxication', or overstimulation, manifested by the patient. This is exactly the opposite of the feelings of the depressed person. In the manic phase the person feels too good, in a state of extreme excitement and hyperactivity. From now on I shall refer to the manic phase of this illness as the "up" period, and I shall return to this subject in more detail later.

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Observe now figure 1 where six variants of manic-depressive illness are exemplified. You will notice that in the typical form (diagram C) phases of depressed or 'down' moods alternate with phases in which the mood is abnormally 'up'. Sometimes the 'up' phase immediately precedes the depressed phase. A complete cycle consists of an 'up' and a 'down' phase. The average duration of the cycle (measured from one depression to the next) varies from six months to five years or more.

You will also notice in Figure 1 that one can be faced with recurrent periods of acute depression, acute mania (graphs A and B), chronic depression, chronic mania (graphs D and E), or mixed and unpredictable cycles (graph F). Graph A shows how depressive episodes can follow one another without an intermediate 'up' phase. In this case we speak of manic-depressed. Diagram B shows cycles composed exclusively of 'up' episodes without intermediate depressive phases; in this second case we speak of a manic-depressed manic. These may seem rather clumsy to you, but what counts is the clinical effectiveness in describing the cycle that the doctor has to treat.

What are the timing of onset and recurrence of depression in this disease?

The first depression usually occurs in people in their thirties, although it can appear in their twenties or forties. This is true regardless of gender. Each successive episode seems to be a repetition of the first, although it may be of greater or lesser intensity.

In the first paragraph of this chapter I noted that an acute episode can last from one week to four months. If these episodes become chronic, remission may take up to a year or more. This remission can last from two to fifteen years (or hopefully indefinitely). I have personally seen cases of patients in whom there had been only two acute episodes, while in others (rarer) there had been ten or more recurrences. The spontaneous remission of these episodes is precisely the feature that gives this disease its specific identity.

The first depressive episode in manic-depressive illness

At the onset of the first depressive episode, you may be vaguely aware of the fact that your family member has recently been getting little sleep and complaining of persistent tiredness. You wouldn't know when exactly it started, but weeks go by, and you finally realise that something is wrong. This person wakes up every morning around four or five o'clock, irritated and despondent. Once she wakes up, she can't go back to sleep, which irritates her even more. Once she is out of bed, getting her out of the house to go to work is almost a challenge. She will tell you that the day ahead seems endless. Her own feelings disconcert her, and she tries to fight them, promising with a half smile that she will try to make an effort and get out of it. When she comes home in the evening, she may feel a little better and maybe go out to visit someone. But the next morning it is the same story again. Day after day, the situation shows no signs of improving.

If the symptoms remained at this level, mild depression could be diagnosed. With appropriate treatment, the patient would recover without too much difficulty. As the symptoms worsen, however, the depression becomes more

acute. At this stage the patient loses all interest in work, and later in his own appearance. He becomes irritable and short-tempered towards everything and everyone, and claims to feel drained of energy. Vitamins and rest in as quiet an environment as possible have no effect. He also complained of stomach upsets, nausea, headaches and attacks of vertigo. Blood tests, X-rays and physical examination reveal nothing in particular; the doctor may then suggest that the patient is simply "tired and nervous". As a last resort, you take him on a trip "for a change of scenery".

But even on holiday he shows little interest in company, food or entertainment. He constantly feels down in the dumps and cannot cope with the slightest problem - what to wear, what to order in the restaurant, or whether to read, walk or rest. And when he finally begins to wonder aloud whether everyone is against him, and at the same time feels sorry for himself and blames himself as a 'failure', then you think it's time to take him home.

And you did well. By now he is showing the symptoms of an ongoing, acute and agitated (in some cases delayed) depression. It may have taken a few weeks or months for the illness to develop, but now the crisis has erupted.

If the patient undergoes intensive treatment there are more than reasonable hopes of full recovery in a relatively short time (four to six weeks). But if the appropriate treatment is not given, the depression may persist at this level for a period of three months to two years or more, not to mention the case of the patient's condition deteriorating to such an extent that it is conducive to suicide.

The onset of the second depression

Once the patient seems to be cured, it is only natural that you do not even want to consider the possibility of a relapse. There is nothing strange about this,

because it is clear that nobody likes to live with such a sword of Damocles over their head. But if you should nevertheless realise that depression has reappeared, your first reaction may be to sigh and think: here we go again.

This is not entirely accurate. Taught by experience, you are able to recognise the first symptoms immediately. Once you have seen your family member happily overcome the first depression following treatment, you will not hesitate to take the necessary steps. This will eliminate all the uncertainty and guesswork, and can make a decisive contribution to shortening both the illness and the treatment period.

What does the expression 'manic episode' mean?

Let us return again to figure 1. I noted earlier that an 'up' (or manic) episode may, depending on the case, precede or follow the depressive episode. Both phenomena take place in regular or mixed patterns of the illness (graphs C and F).

A typical 'up' episode appears suddenly. Seemingly overnight, and certainly within a few days, the person appears bursting with ideas. He does not sleep for more than a few hours, but wakes up feeling very well. It is true that she does not have a great appetite, but this is because she is 'too busy' to eat, and there are 'more important things than food'. Busy, she comes up with a new idea every day and tries to involve you in her exciting projects. She spends and spends, and overwhelms everyone she comes across with statements of unbridled optimism.

YOU CANNOT CALM HER DOWN. When you try to reason with her or criticise her ideas, she will become angry and even violent. If you point out the irrationality of her plans, she will laugh at your "short-sightedness". She will be rebellious against any attempt to control her. Cure herself? Ridiculous. To be

examined? Why would she do that? There's nothing wrong with her. There is. Everything's fine. He's better than you, and better than any doctor. Everything's going swimmingly.

You feel overwhelmed.

Such a form of emotional exaggeration, when the person is engaged in continuous hyperactivity, is called hypomania (where fp() means 'less than': i.e. less than mania). In such cases it is essential to seek medical advice, because from this phase the patient may suddenly move into one of acute depression. The abrupt change from continuous intoxication to deep depression is a clear warning sign of danger. After experiencing such a period of exaltation, the person is no longer able to cope with sadness. The nervous system will not cope with this sudden drop in tension energy, and the person may commit suicide before you have even had time to realise that his mood has plummeted from the heights on which he was standing.

However, such 'up' episodes do not necessarily lead to depression. In some cases they may last for weeks or months, and even become chronic on the higher levels.

What are the causes of manic-depressive disorders?

It is a fairly common misconception that this illness is inherent in personality development. This would mean that if an individual is happy, bubbly and extroverted these characteristics would make him or her prone to manicdepressive disorders. There is no well-founded reason to such an argument. If you look at Figure 1 again, you will see from the graphs that the shy, introverted person may be just as prone to manic depression as the extroverted person, just as it may well be that people of either type are not prone

to it at all.

In my opinion, the manic-depressive cycle is primarily a physiological and metabolic imbalance of the nervous system. A great deal of research carried out over the last fifteen years on brain function has shown that it is precisely chemical changes linked to an abnormal functioning of the brain's metabolism that interfere with the neural circuits and slow down or accelerate nervous activity. Phenomena of this kind, depending on the phase of the cycle, may give rise to depression or excitement; and from this follows a distortion of the rational faculties of the person, a disturbance of his behaviour, fluctuations in emotional states, and a situation of general physical and psychic imbalance.

Are there 'up' and 'down' phases in the normal individual as well?

Certainly. You will undoubtedly know someone who is sometimes sad and sometimes cheerful and euphoric. This does not mean, however, that this person is on the road to manic-depressive illness. There are biological rhythms in the nervous functions that follow each other like day and night, or the seasons in the course of the year. Changes in mood can therefore be considered normal, within relatively wide limits.

Even when there have been manic-depressive episodes in a person's history, different people may settle on different levels of emotional life. One individual may function normally on the levels of a quiet and accommodating personality, another may travel at the glowing pace of the 'human dynamo', like certain characters whose extraordinary gifts make them legendary. The range of normality within which a person can stabilise without ever relapsing into episodes of excessive 'up' or 'down' is therefore very wide.

If, however, your family member is the kind of person who sometimes feels

uneasy about his or her own emotional processes, invite him or her to see the doctor or psychiatrist from time to time, if only to remove any cause for concern.

Psychotic depression (in schizophrenia)

I have already defined (in chapter one) psychosis. You have probably already heard the term schizophrenia used. In general, this term indicates a certain type of psychotic disorder. Here I would like to focus on the particular type of schizophrenia that is accompanied by a depressive state. In this case depression is a symptom that helps to reveal the presence of psychosis.

It could be, for example, that there is a teenage daughter in the family who is beginning to cause concern. One day she came home from school upset and announced that she had decided to stop studying. Since then she has hardly left the house, seems despondent, and boys, sports and friendships no longer seem to hold any interest for her; she does practically nothing, is clearly apathetic and indifferent. Pale, with bags under her eyes, she drags herself from one side of the house to the other, looking sad and confused. This behaviour worries you and you would like her to get over this period and stop making "all that fuss".

Your concerns are certainly justified; but where you are wrong is in your interpretation of his manner, because the symptoms are those of a delayed depression (and to this is due his 'slowing down').

Occurrence of psychosis

Symptoms of another kind begin to appear. These now refer to the primary disorder, i.e. schizophrenia. The girl complains that "everything seems blurred,

confused, disconnected. I feel like I'm stuck inside. Familiar objects and people seem strange and distorted. Hallucinations may occur; she may hear voices or see objects that are not there. She may also experience delusions of persecution; or she may fall prey to fantasies of grandeur. Sleeping during the day and staying awake at night, she now lives in a world of her own from which everyone else is excluded. You could describe her condition in the words of this mother: 'She sits there, but I don't know where she really is. She's not in the room, and she's not in this world either, doctor".

At this point, new symptoms of depression appear. The girl cries, insults herself with the worst of insults, then falls into despair. At the same time, she becomes increasingly unable to distinguish between her fantasies and reality. Depression and schizophrenia are intertwined in a single illness.

But while schizophrenia is by far the principal disorder, and it is to this that the mental processes, the impaired judgment, and the inability to control behaviour are attributed, the immediate and more serious problem is the intensity of the depressive state; schizophrenic depression is the number one reason for suicide among adolescents and young adults, male and female, aged fifteen to twentyfive. If the depressive state is not immediately addressed, it may be too late to treat schizophrenia, because I can assure you from my own experience that the patient may soon escape all treatment options by suicide.

The general treatment programme for this type of depression will naturally also include treatment of the schizophrenic process itself.

Postpartum depression (after childbirth)

Many women go through a period of depression after giving birth. This is quite common. You may have attributed it to sheer physical fatigue, especially in cases

of prolonged labour and difficult births. This feeling of despondency can also lead to a slight depression, which resolves itself within a week or so - and this is a fairly common reaction.

However, if this postnatal depressive state lasts longer or becomes more intense, it can lead to serious problems.

The moderate phase

I could be talking about your wife. After the birth of the child you noticed the slight depression I mentioned above, but this did not particularly worry you. You looked for help, a nanny or a relative who could help, and you thought that this would certainly solve the problem. However, several weeks have ed and your wife shows no signs of recovery. On the contrary, her symptoms are getting worse and she seems to you to be getting more and more dejected and confused.

On top of that she is upset that she cannot experience the sweet sensations of motherhood as she had expected. No doubt, she would love to feel close to her baby, but her feelings are mixed. She cannot find the emotional strength to breastfeed and give her baby the care it needs, nor does she feel any real desire to do so. Returning to housework would then be a task beyond her possibilities.

She cries constantly, refuses food, and winces every time the phone rings or the doorbell rings. As in most endogenous depressions, she wakes up too early and cannot go back to sleep, tense as she is and obsessed by all sorts of thoughts. What would happen if she accidentally let the child slip through her fingers or suffocate him? She is afraid to even touch him, because of her strange thoughts and the disturbing impulses she feels. He no longer trusts himself to do the slightest thing, every ten minutes he is on the phone asking for help.

At this point the depression is not yet too serious; if it is recognised for what it is, it can be treated effectively without further consequences.

If depression progresses and becomes severe

Your wife becomes more and more intractable and irrational. She will cry that you no longer love her, that you no longer care for her. Your supposed indifference causes fits of rage. These ideas can take on the proportions of paranoid delusions. She will insist that you are trying to get rid of her, or that people are gossiping about her, and word has spread that she is a sexual pervert. And in reaction to distorted ideas of this kind, she will try to strike at you, her parents, and her friends, in the firm belief that behind each of them lies an implacable enemy.

At this crucial stage, the only way to suppress depression within a reasonable timeframe is intensive treatment; the alternative is long-term chronic depression that can take months and months to overcome.

What are the causes of postnatal depression?

Apparently, the young mother is particularly sensitive to the physiochemical and glandular metabolism changes induced by pregnancy and childbirth. Obviously, these changes are natural and not at all unexpected. However, in particular cases, they can be so stressful that they exceed the tolerance of the nervous system, thus triggering serious imbalances in psychic functions. (Sometimes another type of post-partum depression appears, which I intend to discuss in the section on neurotic depressions; see Chapter V).

Is there a possibility of further episodes of depression at subsequent births?

They can occur, but they do not necessarily have to. The first episode can occur at the birth of the first child or the second or third, whatever the age of the mother. In most cases it occurs at the time of the first birth, or in the case of particularly susceptible women between the ages of twenty-five and thirty-five. However, there is no reason to think that an episode of depression of this type should necessarily be followed by a second one with the birth of another child. In general, this type of depression does not tend to recur, although there are cases of recurrence in subsequent pregnancies. In this field there is no way of saying anything with absolute certainty, but in general I would advise a mother who has come through a first episode satisfactorily and is in good health to go ahead with her plans for another child without worrying about the complications of the previous birth.

Depression due to old age (senility)

As the likelihood of old age increases, older people today face a whole range of problems for which they are not prepared. Retirement, the onset of chronic illnesses, the difficulty of coping with social changes, children growing up and leaving home, old friends leaving one by one, the need to move to a new environment: all this is compounded by physical changes; just as ageing leaves its mark on the skin and other parts of the body, so it affects the brain and the nervous system. The hardening of arteries and other blood vessels reduces the flow of blood to the brain, and this often results in endogenous depression.

When you become aware of depression

In this case you may be one of the millions of adult children who see their parents succumbing to the ageing process. In your case it could be your father. You have not had too much difficulty in accepting his deteriorating memory and other evidence to that effect: 'you know, that's old age'. But at some point you feel that he is really giving out. If before he was only a little bit irritable, now he has switched to shouting and insults. If you telephone him, he commands you to visit him more often; but when you come to him, he greets you with a rant: you are ruining your business, he shouts, and you are behaving irresponsibly and selfishly. He may ask why God should have punished him with such ungrateful children. You may think that he must be confusing you with someone else, because he is accusing you of plotting to "rob him of all he has". "Who, me?" you might ask, looking around. When you finally manage to leave, you feel upside down. On top of that, you notice that he hardly touches food, and that he sometimes bursts into tears for no apparent reason. He is also losing weight rapidly, and you begin to worry about his health. But no matter how cautious you try to be in expressing your concerns about this, any hint is enough to trigger new fits of fury.

Or it could be your mother

Lately she has been complaining that she is too old to be of any use to anyone and that nobody cares about her anymore. If you try to discuss this lovingly, she gets very excited and accuses you of being a hypocrite. (And this in itself is unusual, as she has always been a mild and quiet person). ) Nothing seems to give her pleasure any more. It seems that life has become an unbearable burden for her, and she dismisses every display of affection from her children and grandchildren as false. Every slightest change in the daily routine irritates her deeply. However, her mood can change from one moment to the next. In darker moments, when the psychic suffering of depression becomes excessive, she pities herself by crying. She sobs about being alone and abandoned, and the spectacle of rapid decline she offers is disheartening.

It is painful to see one of the parents in this condition. I have treated many

elderly people who have reached this stage. The changes in their brain structures have resulted in a depressive state. This has consequently damaged their personal relationships, even with their nearest and dearest. But however upsetting the picture of this disorder may seem, fortunately today we have the means to remedy it. The treatment of elderly patients suffering from endogenous depression often results in long periods of remission. The patient's return to normality and the stabilisation of his or her emotional state can be a moving and dramatic event - an event that often surprises the whole family, which had given up all hope of recovery.

Toxic depression caused by the use of drugs and medication

Every drug and medicine, as a chemical substance, alters physical and/or mental functions. This is exactly the reason why medicines are prescribed. But in certain cases, you may have an abnormal sensitivity to a particular substance. For example, you may know from experience that aspirin causes heartburn; or that certain medicines can cause reactions such as sweating, dizziness or flushing. If you happen to drink too much coffee, too much tea, or too much Coca-Cola, the caffeine (or similar substances) contained in these drinks can over-stimulate your heart or lungs, leading to palpitations and breathlessness. Such reactions are called side effects. As a rule, these are not serious complaints, although they can be quite annoying. In certain cases, however, the side effects can become serious, and we speak of a toxic reaction. (For a further discussion of side effects, see Chapter X).

If the toxic reaction to a drug occurs in the brain or nervous system, acute depression may then set in.

Symptoms of toxicity

Perhaps one of your family has taken excessive doses of some sedative (see section on drug addiction in Chapter II). He then becomes distracted and indifferent to everything around him. He can no longer concentrate on anything, and seems to have lost all vitality. He expresses himself in plaintive tones, can no longer see anyone, and seems drained and exhausted. If the drug belongs to the newly discovered class of tranquillisers, he may show symptoms of restlessness and agitation. This may indicate the onset of toxic depression. And whether the individual shows a slowdown or agitation, one thing is clear - he or she is 'high'.

The toxicity of the drug may also give rise to illogical and extravagant thoughts that interfere with judgment. For example, a man may gather all his strength, despite the discomfort of the disease, and decide that he wants to go bowling. What if the bowling alley closes in ten minutes? It doesn't matter, he knows they will keep it open for him. Or he will announce around midnight that he is going to make a long-distance call to his brother to demand payment of a small tenyear-old debt, which he himself has long since waived. Try to discuss the matter, explaining to him that this does not seem appropriate and that he will certainly regret it the next day. He does not give the slightest weight to your words and shouts: 'Don't talk nonsense. You don't need to tell me what to do!".

The intoxicating effect usually disappears within 24 to 48 hours, once the body has eliminated the substance responsible. Sometimes, however, the depressive effect of intoxication lasts much longer because the nervous system has been too badly decompensated to recover immediately. Antidepressant treatment is therefore appropriate.

Depressions caused by infections

Endogenous depression can be induced not only by specific infections of brain and nerve tissue, but also by generalised infections of the body.

When the infection specifically affects the brain and nervous system, as in meningitis or encephalitis, the most prominent symptoms are high fever, delirium and comatose state. This is the acute phase of the brain infection. Once this phase has ed, however, the whole family breathes a sigh of relief and considers the disease to be over.

But to everyone's dismay, the patient can now show signs of deep depression: the infection has also caused an imbalance in the nervous system. The person has fits of uncontrollable crying for which he cannot give a precise reason. His mental and physical functions will slow down (or, in certain cases, he will be restless and agitated). This condition may persist for several months after clinical recovery from the infection before it is recognised for what it really is depression.

When a generalised infection invades the body, such as in a virus disease, it can have a toxic effect on the brain and nervous system, and a depressive state can follow for a period of one to two months.

I recently treated a patient whose case was precisely this. She was a woman in her fifties, exuberant and cheerful, and with a marked sense of humour. Recovering from a severe viral infection, she felt 'weak as a kitten' and deeply dejected. Her fears about her condition contributed to her depression. This was clearly a delayed depression, which should have disappeared when she recovered from the generalised infection, but it did not, and eventually antidepressant treatment was required.

I suspect that many viral infections, which have become epidemic in recent years, also affect the nervous system and consequently induce a delayed depression - usually of moderate intensity - which the individual does not always manage to overcome easily. These emotional disorders should be detected and

treated as early as possible, before they have time to become chronic.

Depression related to glandular disorders

You may have heard about the influence of glandular secretions (hormones) on the body's normal functions. Perhaps you know someone who has 'glandular disorders'. But you probably do not exactly realise the extent to which this kind of problem affects a person's emotional state.

Suppose you are an individual with poor thyroid function. You will then notice a significant tendency towards apathy. And indeed there is a general tendency to regard him as a somewhat dull person, since the thinking processes are slowed down, and there are apparently memory blocks. In reality, however, this person may be of completely normal intelligence, the real problem being the delayed depression associated with a hypothyroid condition.

At the opposite pole is the individual with an overactive or toxic thyroid (hyperthyroidism), who can be both depressed and agitated. He is always tense and prone to explode at the slightest obstacle.

Another case might be a woman with imbalances in the hormonal functions of the ovaries; these give rise to premenstrual tension, a fairly common type of nervousness that appears a few days before the period. If this condition is excessive, the state of nervousness and mild depression can put too much strain on the nervous system to be easily overcome every time.

In another case there may be an imbalance in the secretions of the pituitary gland (at the base of the brain) or the adrenal glands (which reside above the lungs). If

you have ever dealt with people undergoing treatment for such disorders, you will probably have realised that abnormal secretion of these glands can also lead to a severe form of depression. Related to this can be a pattern of physical symptoms such as high blood pressure, hirsutism (excessive hair growth), dry skin, headaches and fainting spells.

Illness and treatment

Many of these glandular disorders are rather refractory to treatment, but in certain cases good results are achieved with the istration of purified substances analogous to natural hormones. These substances compensate for hormonal deficiencies, and help to lift the patient out of a depressive state.

Here, however, lies the paradox. Certain hormone-based medicines, such as the contraceptive pill or certain corticosteroids, can cause depression if the person is too sensitive to them or takes too large a dose. I have seen many such cases myself, such as the recent case of a woman who became depressed after taking hormones prescribed for the menopause.

Although depression caused by a glandular disorder or hormone treatment is not a very common phenomenon, it does occur in certain cases, and if not dealt with promptly it can worsen and prolong over time.

Depression following accidents

If one of your acquaintances has been in a car accident or any other kind of physical accident, he or she has probably suffered what is called 'shock'. In the state of shock, blood circulation in the body and brain slows down, and blood

pressure drops abruptly. At the same time other chemical changes in the body produce a general collapse of nerve functions. The person seems stupefied, and this can be clearly seen.

Due to the damage caused to the functioning of the nervous system, the state of shock is often followed by an episode of depression. Depression (usually of the delayed type) only lasts until the normal function of the nervous system has been restored. Once the nervous system has recovered, the depression should disappear. But as long as it lasts, it definitely requires psychiatric treatment.

Postoperative depression

An aunt convalescing from an operation raises your concern. The doctor has assured you that the operation was a complete success. But your aunt has lost her appetite, and does not seem to care at all about her condition, as if she thought she would never recover. The doctor is concerned about this attitude, which makes the healing process difficult and prevents recovery. And you wonder why, with her whole life ahead of her, she is so discouraged about the future.

Well, the first thing to bear in mind is that the operation was certainly no fun. Even with the new anaesthetic techniques and modern operating procedures, your aunt was under a great deal of physical stress. Many people come out of this stress so debilitated that the exhaustion of nervous energy leads to endogenous depression. And this complicates and prolongs the postoperative course.

Secondly, a positive frame of mind ensures that the patient eats well and recovers lost energy through sleep, and helps maintain good muscle tone. All this makes an essential contribution to the healing process.

But with the depressive state, the nervous system and the organism in general relax. Convalescence then extends well beyond the time required by the operation itself. I know of cases where postoperative depression was not diagnosed and the patient died. The surgeon and the other doctors involved cannot find any medical reason for the death in these cases. What I personally believe is that such a patient actually 'commits suicide': it is his depressive state that causes him to seek death in the aftermath of the operation.

A depressive state can be assumed when the patient eats little, sleeps irregularly, and by the rather peculiar fact that he complains very little. Nothing else matters, not even pain or discomfort. The patient seems to be giving in to death, as if thinking: "My life is over. Whatever happens, what difference does it make?".

Depression following changes in body structure

Men and women who lose a part of their body as a result of an accident or an illness with subsequent surgery may fall into a state of acute depression if any of the following conditions occur: first, when the loss of the body part carries a personal significance that gives rise to a strong emotional reaction to the loss; for example, an operation or accident may alter the genital or other sexually characterised organs, and this may then give rise to a sense of castration. Second, when the loss of a body part affects a person's usual way of earning a living, as in the case of a pianist who loses a hand. Third, when the change in the structure of the body interferes with certain functions, and the person is thus partially or totally disabled. Fourth, when the necessary alteration of the body presents itself as a serious and intolerable blow to the person's self-image. When the individual is unable to cope with any of the above conditions, and when satisfactory or at least compensatory alternatives are lacking, an acute state of depression ensues.

Depression linked to acute or chronic illness

Every illness, short or long, acts as a stressor on the body and nervous system. A woman, for example, suffers from a chronic ulcer; the suffering and the strict diet soon tear her nerves to shreds: 'she can't take it any more'. For others, the intolerable stress may be due to arthritis, chronic prostatitis, a heart condition or lung disease.

I recently treated a man in his forties, a craftsman who was fully satisfied with his work and had a good family. For him, the long hours of hard work had never been a burden, but now the persistent discomfort of a chronic spinal cord compression with sciatica tormented him relentlessly. Worn down by his physical symptoms to the point of depression, he had lost a lot of interest in life, and above all he was showing less and less interest in the active treatment of his sciatica. He had had enough. "Life is too hard, if I have to drag myself through this suffering every day," he had told his wife.

Suppose that this person's health was your responsibility. You probably could not understand why he did not even seem to care about the very medical treatment that could relieve most of his pain. But once the person has fallen into the depressive state, the latter also dulls the very instinct to heal, and until it has been treated the individual will not be able to re-motivate himself and acquire the energy necessary to face the medical treatment or the intensive surgical treatment that has meanwhile become opportune and decisive in overcoming the illness.

Depression caused by physical or mental fatigue

You will no doubt be familiar with certain expressions referring to certain categories of people who are particularly caught up in the struggle and competition typical of our society and culture. A partial list will refresh your memory in this respect.

The nervous housewife.

The debt-ridden worker.

The busy businessman.

The trader full of worries.

The frustrated state.

The excluded.

Any victim of the Age of Anxiety.

Stress reactions to fatigue

The human organism can absorb even considerable levels of stress; but at an excessive level, the point of overload is reached. We are all subject to this rule. At the breaking point, depression can set in. If fatigue has pushed the person beyond his or her tolerance limits, you will see him or her too tired to think, move, eat, make love, converse or even welcome good news.

This phenomenon is completely different from the fatigue that normally follows a day's work. It is something qualitatively different from the fatigue that follows a bicycle ride, dancing the night away, or a Sunday cleaning of the cellar done for the sake of it. In these situations one can still enjoy a good meal, an evening at the movies, or some other form of distraction, and the fatigue disappears with a little rest or a night's sleep.

No, the exhaustion of nervous energy of which I speak appears from a situation of chronic stress: the constant friction of a bad marriage, the despair of life in the barracks, a superior who is too hard and demanding, the tyranny of industrial employment, the insensitivity of bureaucratic control, war, social upheavals, and so on. An acute depression of the nervous functions becomes inevitable. These fatigue reactions are technically a depletion of the reserves of adaptation; but they also contribute to a chemical imbalance in the brain and the nervous system which leads to endogenous depression. For rapid recovery, only a programme that combines physical therapy with the elimination of the stressful situation can bring the person back to a normal level of emotional stability.

Stress reaction as a result of caring for a depressed person

It is a paradox that many well-meaning people with a sincere sense of empathy, in their zeal to offer every care to a depressed family member, end up falling into a state of depression themselves, because they have overestimated their physical and emotional resources in caring for the patient. Driven by affection, devotion, or even by a strong sense of duty, they give up their personal interests, ignore all other obligations, deprive themselves of sleep and rest, and above all identify so closely with the depressed person that they experience the torment of his suffering at first hand. All this soon leads to a depletion of their adaptive energy. It is therefore advisable that you measure your limits carefully and do not allow yourself to fall into martyrdom. When this is possible, it is certainly better to share the burden of the illness with others, so that when the patient succeeds in recovering, as happens in most cases, you will be able to cope with the family's return to normality with sufficient energy.

IV. WHAT YOU SHOULD KNOW ABOUT REACTIVE DEPRESSION: PAIN

The essence of reactive depression is a vivid sense of loss. The person feels that every possibility of permanence has collapsed and that his or her patterns of survival and security have been shattered. The loss - whether real or symbolic seems so irreparable that the only way to deal with it is to mourn inconsolably: the empty space will never be filled again. This situation of mourning, or grief, constitutes reactive depression.

Depression caused by a death

Let us suppose, to illustrate the situation with an example, that someone close to you has recently lost her husband. You had no problem with empathy: you immediately felt deeply involved. You yourself could not say how a person can overcome such grief, and you thought that surely for this woman life could never be the same again.

After the initial moment, your acquaintance seemed numb and slowed down in her actions. Every little task she had to carry out cost her immense efforts. She then entered a phase of increasing isolation and silence, even if at times she seemed very agitated. She did not sleep very well, except for a few periods when she somehow managed to rest better. But these were of short duration. Even if sleep gave her a certain relief, as the hours ed, the memory became more vivid and more present, and again the tears and sadness returned.

But now more than two years have ed, and she continues to live in semi-

darkness, refusing to leave the house. No matter how hard she tries to sleep, she never feels rested. Sometimes you even wonder if she isn't playing the part of the inconsolable widow for some hidden reason, but you dismiss these thoughts as totally inappropriate. You would, however, like to make her stop relying only on you; you organise evenings at the theatre, pick her up at home in your car (although this is undoubtedly a burden for you), take her to your house, and try in every way to distract her. But every conversation inevitably comes back to the same subject - her broken heart, her destroyed life. What can she do now? Where can she go? It seems that somehow she means that it was not just a loss, but a betrayal.

Eventually you get to the point where you recognise to yourself (beyond feelings and guilt) that you can't take it anymore. How long can you go on like this?

How long should this type of pain reaction normally last?

Many religions and cultures establish a traditional period of mourning, varying from twenty-four hours to a year or more. This kind of tradition, present in the history of every society, confirms the human need to put an end to grief; and it tells us that this grief cannot last forever.

In some cases, however, the loss can take on such proportions that the person in question is unable to find sufficient compensation, and so lives a life centred on their grief; and if this form of chronic depression is not treated, it can accompany the person for the rest of their days. You may have known parents who grieve the loss of a child years and years after his or her death, with no sign that their grief will subside.

The difference between a normal grief reaction, which es within a reasonable period, and this kind of intense and prolonged reaction to a loss that

the person can no longer overcome lies in the individual personality prior to the loss. This may be the case, for example, of a personality in which dependency is the predominant trait (as with the widow described). Or it may be a rigid and perfectionistic character structure, which gives rise to intense feelings of guilt about the death. Or it may also be the case of an immature and anxious personality that makes the individual dwell on every detail and relive it with great intensity in the face of anything that reminds him or her of the deceased person. In all these cases, depression continues to feed on itself, since any capacity to respond to corroborative stimuli that would conveniently guarantee emotional self-sufficiency has finally been eroded by pre-existing personality failures.

Depression caused by other losses

Following the loss of material objects, or of an opportunity, a relationship, a job, or even what is called 'face', the same kind of delayed depression can occur as in the case of the disappearance of a loved one.

Let's take a case that is quite common today; a person suffers a theft. Let us assume that the damage is covered by insurance. This may be followed by a mild depression, which is short-lived: it should disappear fairly quickly once the damage has been compensated. One of my patients could not emotionally cope with the fact that an ant, in whom he had placed the utmost trust, had misappropriated certain sums. The damage was twofold; he had not only lost a considerable amount of money, he had also lost all confidence in his employees and business partners. His state of depression was underlined by the bitter philosophy that 'you can't trust anyone anymore'. Fortunately, this state of depression did not turn into a real paranoia, because his manager managed to compensate for part of the loss by turning it into a reason for tax exemption; moreover, the other employees rallied around him and showed him such loyalty that his trust in others was restored, and he soon managed to get rid of his depression.

You can probably think of other cases of acquaintances of yours where a loss has been followed by reactive depression; it may have been the loss of a good job for which the person in question was particularly qualified; or the interruption of studies; or the loss of a 'once-in-a-lifetime' opportunity to buy a certain house; or the lost opportunity to marry 'the perfect person'; or being forced to leave a certain position of prestige with a consequent reduction in social status. The individual can no longer look to the future, and spends years and years mourning in a state of moderate depression characterised by 'grief' and resentment about the loss which he cannot compensate for in other ways.

Depression caused by a change in situation

Dramatic changes of situation may hit the individual with the impact of a brutal deprivation, so much so that he or she may think of a collapse of his or her existential foundations. Such a change may be represented by retirement, divorce or separation, a transfer, a change of job, a situation of isolation and loneliness, and so on. A depressive state then follows.

Retirement

This may be your husband, who has recently retired. Leaving work or the business has been the focus of his expectations over the last year. From a financial point of view, the situation has been settled in the best possible way. You have heard him talk enthusiastically about all the things he could do - go fishing, take up other hobbies, travel. But above all, he would no longer have to 'get up every morning to go to that damn job'.

Now that retirement is a fait accompli, he has become nervous and is always in a bad mood. He misses his job and his colleagues. OK, fishing was fun for a

while, but 'you can't go fishing all the time'. He enjoys being with his grandchildren, but soon tires of them too. Too restless to enjoy a whole film, he also despises the pensioners' club. "They are old." He says he feels boxed in, that he no longer has a purpose in life. He is unable to adapt to the new routine, and pities the old one.

He is unable to concentrate on the newspaper beyond the headlines, although he 'explains' this by visual disturbances. If you manage to get him out for a walk, he comes home almost immediately, because he feels uncomfortable outside on his own. He begins to fixate on all sorts of ailments, imperiously drawing your attention to one or the other, and if you betray an ounce of impatience he begins to complain about himself and his aches and pains. You had seen retirement as a wonderful holiday for him and for you; but your husband is getting lower and lower, and is becoming a burden on the whole family. From time to time you may think: "after all, I didn't retire...". As a last resort, you then suggest that he go back to work; "Who would want an old man like me?" he replies in a plaintive tone.

You realise that this is a vicious circle and that there is something wrong with his depressed state. But you don't know what to do - how can you get him out of that impossible state of mind and return him to a normal life?

Divorce

"My best friend can't get over her divorce".

This often happens. When a woman has been married for many years, she adapts to a certain lifestyle and value system, which gives her security. But separation or divorce shatters this security and stability.

You have long ired your friend as a generous and intelligent person. She had been married for fifteen years when she learned that her husband had fallen in love with another woman and wanted to leave the family. She collapsed at this point, certain that she was the one who had 'broken up' the marriage at some unspecified time during all those years. Losing her husband means that her sense of stability, identification and joy has been profoundly disturbed. Legal complications, the problem of children and her new role as a single woman present new difficulties for which she is not prepared.

She also has to cope with adapting to new values and different interests. But the efforts required by this complex of situations are more than she can bear. She then reacts to the loss of her former happiness with a state of grief and depression.

Transfer

When someone 'loses their roots', for whatever reason, they may be quick to discover that the move is more than just 'getting up and going'. One has to leave behind years of friendship - just as one may have to leave behind a lovingly tended garden, the familiar view from the windows or veranda of one's home, the sounds and smells of a house one has lived in for a long time. These points of orientation in time and space help to ensure that the individual can relax and unwind; but relocation cuts these ties. Around every corner the unknown awaits you. Every detail of your daily life must be anticipated in advance.

I think of an elderly colleague of mine, who was very attached to his home and his friendships and was forced to move to a drier climate because of his wife's health. Their mutual devotion made this sacrifice seem to him to be a light one.

Once in his new environment, however, the lack of the usual places and relationships soon undermined his stoicism. Nostalgia prevented him from thinking about anything else. The depression that emerged from this change of situation had all the characteristics of a generalised grief reaction, so intense that it eventually required the treatment and sensitive of a colleague. It was only when the colleague helped him to integrate into the new community and to forge new ties within it that he was able to sufficiently compensate for the loss of his former life.

Loneliness

They are more than what you think of as 'outcasts' from the family or society. Many of those who find themselves in a situation of loneliness and isolation are normal people, but chance, or some physical or psychic characteristic, has excluded them from society, in a condition of exclusion and maladjustment. Such a blow to the structures of the ego shatters the integrity of the person: no one can live in a condition of isolation without paying the price.

Belonging to a group with strong ties of identification constitutes, biologically and socially, an essential need for individual survival. The person who does not belong reacts to the lack of existential place with anxiety, fear and anger, and is pushed to the limit of despair. Let us consider, for example, the case of the lonely girl who leaves home and goes to live in a big city, without being able to make new friends. If this gives her a self-image of failure and total worthlessness in life, she may gradually slip into depression, ending up as one of the many cases of suicide 'for no apparent reason'.

The case of all those people who endure a situation of loneliness even without being alone cannot be overlooked; they may be children, adolescents, or married people with families; but the person feels excluded, out of place for all intents and purposes. A teenager may feel the neglect of divorced parents who do not accept him. A wife may feel the full weight of the indifference of her husband,

who is more interested in work or fun than in her. Or a divorced woman, already victimised by a psychopathic husband, may return home only to suffer constant reproaches from parents who refuse to forgive her for her 'mistake'. "It's not our business. You have to get out of trouble yourself."

For people in such situations, the present offers no reason for gratification, and the future appears to be a dead end. The obvious conclusion may then be a reactive depression.

V. WHAT YOU SHOULD KNOW ABOUT NEUROTIC DEPRESSIONS

This type of depression is rooted in the individual's neurotic personality (with adaptation difficulties).

Neurotic people start with an initial disadvantage in of maintaining emotional stability. Unable to withstand the average levels of tension imposed by everyday life, they are unable to regain sufficient strength in the struggle against those obstacles that normally confront people in our society. On the contrary, their emotional fibre is weakened as they burn up all their reserves of nervous energy at every confrontation with life. The state of exhaustion that follows makes them easy targets for depression.

At this point you might object: 'But can there not be some truth in all the jokes that circulate about neurosis? Isn't it true that we are all a bit neurotic - a bit brain dead?". Of course, if one stays within the limits of the witty joke. But from the psychiatrist's point of view, the term neurosis has a precise technical and clinical meaning that the lay observer may not know.

"WHO IS NOT NEUROTIC, THEN?". Rather, this is the question we must ask ourselves; or at least the one that is easiest to answer, although I would like to examine the question from both sides.

It is possible to some extent to define a norm on psychiatric canons. My personal yardstick of satisfactory personality functioning, reasonably free of neurotic tension, is based on three basic requirements:

1. Adequacy: the expression of a person's recognised potential. The closer the person comes to this, the more psychologically healthy he or she can be.

2. Efficiency: the extent of one's contribution to society in relation to the costs of maintaining it (since in our society's value system everyone has to earn enough to be able to pay for a living).

3. Gratification: the measure of pleasure or satisfaction a person manages to get in life.

In summary, the sufficiently adapted person, in the context of his or her social and economic position, is able to make full use of his or her strengths and abilities, is able to earn a living, and finally obtains a reasonable measure of pleasure and enjoyment from life.

If one or more of these essential conditions are lacking in the personality picture, we are in the presence of a neurosis, and the possibility of depressive states follows. The inevitability of a depletion of the reserves of adaptation and the consequent depressive state cannot be stated as a rule here, but in the case of the neurotic the tendency to such developments is certainly always present.

It is quite likely that you have encountered in your life some of the characters I am about to describe. In Chapter I, for example, I spoke of individuals who live in a state of excessive anxiety or fear, or of constant anger and rebellion, and who are thus likely candidates for depression. The same is true of the immature personality who lives in a state of constant agitation, convinced that he has been cheated by life; the person who feels inadequate, overwhelmed by a sense of inferiority; the cunning and charming psychopath who lies, cheats, steals, and

cares only for himself and his own pleasure, but who at the same time is prone to fall prey to depression when fortune ceases to assist him; the eternal worrier, always trembling at the thought of what might happen to him in a moment; the chronic complainer or hypochondriac; the 'psychosomatic' who lives in a state of constant tension and ends up developing disorders such as stomach ulcers, asthma, migraine, colitis, certain types of skin disease, and so on; and the obsessive-compulsive, whose personality is strongly characterised by perfectionism.

The obsessive-compulsive model: a classic pattern of neurotic depression.

In my books, lectures and in this book itself, I have used the concept of 'depletion of adaptive energy' to characterise a certain type of process that can lead to depression. This concept applies especially to neurotic depression, and one of its most frequent victims is the obsessive-compulsive personality.

Try to visualise for a moment the classic type of rigid, perfectionist person who feels compelled to be 'right and up to scratch' in all circumstances. Such a person has to perform every action in the right way, or rather, in their way. As soon as someone gets up from the couch, she rushes to fluff the cushions; if there is a cigarette butt in the ashtray, she empties it. Time and money should be managed with scrupulous care. Don't put off until tomorrow what you have to do today, whatever may happen. (Of course you may even have a certain innocent iration for such conscientiousness). But in sticking to the 'right way' such a person does not live by the spirit of the law, but by the letter.

Other traits and characteristics highlight the lack of flexibility of this type of character. If they are obsessed with an idea, these people may feel compelled to 'act on' it. For example, they may not be able to sleep if the shoes next to the bed are not exactly the same size as each other. Or they may have to buy a dozen of the same object all the time. If they put a desk back in place, they cannot proceed until the edges have been thoroughly dusted with a toothbrush. If they leave their

car at a car park, they have to go back four or five times to check that the handbrake is on.

"But isn't he simply a particularly tidy and conscientious person?" you might ask. The answer is: no. However, the questions that need to be asked in order to ascertain the presence of obsessive-compulsive neurosis are: 1. Can the person chase away the recurring thought (obsession)? 2. Can he or she take care of something else, eliminating the compulsive action? Or do anxiety and tension increase as the fixed idea persists, or as long as the action has not been carried out?

When adaptive energy is depleted

In order to keep up with the heavy schedule he has set for himself, the obsessivecompulsive type has to expend enormous amounts of energy. He will tell you that there is no difference between doing things as they come or doing them perfectly. But this also means maintaining a state of continuous attention, without a moment's drift. Such a person, therefore, can never let down his guard or let go of the obsessions and compulsions that form his safety handle. It is precisely this obsessive need for constant vigilance that gradually devours all his energy reserves. It can go on for years, slowly exhausting itself in this way; or it can be the sudden onset of a crisis that requires a great deal of energy and causes rapid exhaustion.

Today's society and culture require more plasticity than such people possess. It is a question of characters and habits that are unable to yield to the demands of the changes that inevitably take place in the family, at work, in the environment and in society; a flexible approach to life becomes impossible. The new situation affirms its necessity; the neurotic's rigidity denies it. And the inevitable defeat is followed by depression.

As I write this, I am reminded of the case of the sister of an old friend of mine. I her very vividly as a woman obsessed with the ideal of an 'immaculate' home, and compulsively determined to pursue it. Her three teenage children, however, were a discordant note to her perfectionist ideal. She became increasingly irritable and devitalised, until she began to feel that the children were deliberately disrupting her routine; this distrust led to paranoid ideas that included everything and everyone. The rigidity of her personality patterns gripped and suffocated any way out. All nervous energy was soon exhausted and a severe state of depression set in.

The picture of the obsessive-compulsive personality, characterised by rigidity and perfectionism, is a complex one. In Chapter III, I mentioned how this personality type in men and women predisposes them to depression in the menopausal period. We will return to this personality type again in discussing guilt in Chapter IX.

Post-partum depression of the neurotic type (in the immature personality)

I defined post-partum depression above as an endogenous type of depression, resulting from a specific physical stress on the nervous system (Chapter III).

As you may recall, I have postponed the discussion of a second type of postpartum depression. This falls into the category of neurotic depression, since it has its roots in causes other than the endogenous type. In the case of the latter I have suggested the hypothesis that the depressive state is precipitated by chemical changes and hormonal imbalances. In this case, however, depression occurs because the psychological reaction to the stress of motherhood undermines the reserves of adaptive energy and personality. In short, the arrival of a child represents a new life situation, with adult responsibilities, to which the young mother cannot adapt. As a result, she falls into a post-partum neurotic depression.

The onset of symptoms

It could be your daughter-in-law, who has just given birth to her first child. Since then she has been sad and restless, and has been sleeping too little. When she returns home, she is quite indifferent to both the baby and her husband, as well as to the help offered to her. She suffers from sudden mood swings and complains that she never really wanted this child. If she is reminded of how much she had longed for motherhood, she may cry out: "I only said that to please my husband" or "I may have wanted it then, but I must have been crazy. Now it's different". At other times she will exclaim: "Why do I have to find this child again?", bitterly regretting that she cannot "give him back". (This reaction is different from that of the mother who, in an endogenous post-partum depression, desperately wants to establish a relationship with the child, and regrets not being able to do so. The neurotic mother feels the very existence of the child as an oppression).

If you congratulate her on her beautiful and healthy child, she will turn on you in a rage. Her attitude turns out to be very contradictory, because a moment later she will tell you that yes, it is a beautiful child; but only to lament her ineptitude in taking care of it. She also keeps brooding: what if the child gets sick and dies? What if she were to harm him? (You will recall that ideas of this kind are also typical of endogenous post-partum depression). ) If she sees a knife, she immediately imagines that she can use it on the baby; or she might throw the baby out of the window.

In short, you are not only dealing with depression, but also with the instability typical of the functioning of the neurotic personality, with all its attendant fears and anxieties. In this type of disorder, treatment must be aimed at getting the patient to overcome not only the depressive symptoms (sadness and despair) but also the imbalances in the personality structure that have led this young woman to the depressive state.

Other types of neurotic depression

Since there are many types of neurotic personalities prone to depression (and many subtypes to be found in more detail), it would be inappropriate to describe them all in this book. Many of the symptoms are also similar or the same in different types. In addition to the obsessive-compulsive type and the immature type predisposed to post-partum depression, I will limit myself here to describing only three other types of neurotic personalities, because they are the ones most frequently encountered in pictures of neurotic depressive states.

Neurotic depression in the inadequate personality

The person I am going to introduce to you is a young man in his thirties. He dropped out of school before he managed to graduate, and in general it can be said that he has never in his life managed to achieve anything in any field. He works in his father's repair shop and takes advantage of his special situation to gain an advantage over the other employees, who naturally resent this. The father then begs his brother to take him in, hoping that in this way he will 'become a man'. The uncle gives him work, not realising the young man's pathetic lack of resources. He tries with the best of intentions to live up to his tasks, but the difficulties, however small, crush him. Immature as he is, or spoilt, or whatever you want to call him, he is simply incapable of working in a situation that requires commitment.

Such people, whom the psychiatrist calls 'inadequate', eventually exhaust their energies trying to give more than they can give, and are then overwhelmed by a keen sense of worthlessness. This condition often heralds the onset of depressive illness.

Neurotic depression in the chronically irritable person

Another young man, who has always been the "little one" of the family, has become rebellious and irritable. He demands fast cars, and when his careless driving wrecks them, he gets off with a shrug of the shoulders. He changes his course of study several times: after all, studying for his degree is the least of his worries. Why struggle? To begin with, he is much smarter than any professor, and he will go further than all of them when the time comes. If you criticise him, he strikes back with contempt, throwing all your presumed faults in your face. At every remark about his conduct he explodes in fits of fury.

His bad temperament and the hostility he shows towards those who approach him do not make him popular. People avoid him, and he realises this, but at this point he can no longer turn back. Pushed to the margins of society, he is easily overcome by depression. This, combined with anger at his condition, may drive him to self-destruction, perhaps as a victim in a car accident he has caused himself.

Neurotic depression in the pathologically fearful personality

Some individuals are so problematised by neurotic fears that they are completely immobilised by them. You might, for example, know someone who closely resembles this 40-year-old woman. Married, living in the suburbs, she can only drive to the nearest supermarket a couple of times a week, but a trip into town is out of the question. If she tried, the heavy traffic would leave her frozen at the wheel, unable to manoeuvre. The very idea of making a journey alone to any destination chills her with fear. On top of that, she sees every twinge and pain as a serious threat to her health; her friends consider her an eternally worried hypochondriac. For her, the future is always full of misfortune. If her husband has to go on a business trip she 'knows' that he will be ill while he is away, she 'knows' that the plane will have an accident, she 'knows' that something will happen. All these fears drive her to shut herself away and prevent any useful

activity. She lives a life of complete social isolation, burdened by feelings of defeat and worthlessness. The first symptoms to appear are psychosomatic, soon followed by the exhaustion of the reserves of adaptation that heralds depression.

The desperate act in neurotic depression

The suicide attempt in the neurotic has revealing qualities. It is used by the neurotic to manoeuvre the family to focus attention on himself, terrorising everyone with his vow of self-destruction. Even so, the dangers posed by such a threat are no less real. Do not defy him; in certain cases the neurotic may momentarily take himself at his word, and fulfil his purpose. Therefore it is not at all the case to mock or underestimate him.

When the opportunity arises, the person suffering from neurotic depression does not usually fail to give advance notice of his decision (he is not set on suicide, as is the case with endogenous or reactive depression). Interpreted in the right way, this signal means: "Even if in the end it will all be a set-up, I am counting on you to get me out of trouble".

However, the situation can get out of control. A depressed woman in hysterics may shout at her son: 'If you don't do as I say, I'll go up on the roof and throw myself off'. In the heat of the argument he may reply, 'Oh yeah? Why don't you do it? In this moment of conflict the woman's judgement may be impaired; that angry retort may drive her to the fatal act, and once in motion she can no longer control her impulse. By the time the other manages to say 'No, I didn't mean it!' it is too late.

Or maybe you have seen someone who, after a violent argument, runs into the kitchen, grabs a knife and shouts: 'I'm going to kill myself, so you'll finally be happy!'. That scene is deliberately provocative, and you would be tempted not to

let it go. But you must first try to calm him down, to the point of taking the knife out of his hands, because if pushed to act impulsively the depressed person may come to use it as he has threatened. In the same way, a person who resents a rejection or a reproach may be tempted to take 'revenge' with an ill-calculated dose of sleeping pills, so that he loses consciousness before he can reach the telephone or call for help.

However melodramatic, hysterical and ridiculous the neurotic's suicide attempt may seem to you, you must always take it literally. The final outcome of the gesture can always be fatal.

Depression in children and adolescents (up to 16 years)

In Chapter II I stated that children and adolescents can also fall prey to depressive states, both endogenous and reactive and neurotic. In the first two categories, the causal patterns are similar to those found in adults. There is, however, a certain difference with regard to the last category, since the term neurotic, as far as children are concerned, applies more to the context of the struggle for normal social development than to rigid psychological complexes.

Lacking experience, knowledge and strength, and at an immature stage in the development of his faculties, the child cannot live up to the conditions imposed by a society based on adult values and competition. It needs protection and, above all, emotional objects with which to identify, and this throughout its development, so that it can develop the necessary ability to confront life. The child is therefore very sensitive to anything that might threaten its security. And he has good reasons for this. You cannot know how often a child's sense of danger is justified.

When children are pawns in the adult game

Children can be abandoned, rejected, forced too early to rely only on themselves, ignored, despised and abused (up to and including mutilation and murder; there is a medical term for child abuse syndrome).

If the parents separate or divorce, such a divided family no longer offers the child the emotional he so badly needs, often at the most crucial time in this respect, namely puberty. Reduced almost to silence by depression, he will complain that 'nobody loves him', that 'nobody wants him', and conclude that 'he doesn't care about anything anymore'. The child's extreme sensitivity gives the depressive state a particularly harrowing character, because melancholy is related to phenomena that are beyond the child's comprehension.

The teenager's plea for help

In the pattern of isolation, the depressed boy is withdrawn and abnormally quiet and reserved. He avoids games and group activities, worrying only about what makes him sick, in the secret hope that someone will notice him. If you try to pull him out of his state by force of authority at this point, he will resist you ively and isolate himself even more, for what he wants above all else is an inordinate amount of love, attention and security. What he is actually saying is: "Now you must give me your every moment and your every thought. You must show me that you love me. If you fail to offer him these proofs (and it can take several months before you understand the situation), the boy will regress and become increasingly silent and depressed.

In the pattern characterised by hostility the dominant traits are anger and rebellion. The boy ditches school, or otherwise poses a disciplinary problem there. At home he is obstinate and ill-tempered. The next phase may be violent. He destroys furniture, smashes his own and other people's objects, and when you try to calm him down during these outbursts, you only succeed in making the

situation worse. However, keep this fact in mind: the tears, the moans and the moments of real pain that you see him go through highlight the depression of the nervous functions which is the deep reason for his hostile behaviour and the general unbalanced situation in which he finds himself.

The counteraction effect () on the depressed child

Once the child has lost any firm foothold that might provide him with a certain security, a regrettable chain reaction sets in. Rejected by adults and peers, he sinks into melancholy, or seethes with anger; the label 'difficult child' is attached to him, and the antipathy he feels in his environment provokes in him counterreactions of hostility, with the result of raising more and more antipathies. The child is confusedly aware that such tactics are doomed to failure, but he lacks the social power and firmness to compromise or to pursue positive goals with the help of firm decisions. Any prospect of a normal life vanishes, and he falls prey to despair. There seems to him no hope of change; and what really dooms the child is the lack of possible alternatives. The choice is only between isolation and rebellion. At a certain point, the seductive idea of self-destruction may come forward, seen both as a relief from psychic pain and as an extreme form of rebellion against 'those'.

In the eyes of the child, however, suicide does not appear as the frightening reality that it appears to the adult. The child cannot fully grasp the meaning of death. As far as he knows, it is not something final and irremediable. A child can point his toy gun at you and shout: "Bang, bang! You are dead. A few moments later he will say to you: 'Good, now you are alive'. Similarly, suicide is also seen through the eyes of fantasy. If he says to you, "I am going to die, so it will be your fault, and you will realise that you should have loved me more," he is trying in some way to communicate his decision to you. The fact is that he expects to be able to come back to life afterwards. And if his threat is mocked or ignored, perhaps unintentionally, he may feel compelled to carry it out, 'just to show you'.

It is difficult for parents to see the signs of depression in their children, and even more difficult for them to see the signs of suicide. Usually it is the insight of an uncle, aunt or friend that is needed to save the child from depression. And perhaps it is up to you.

VI. A TABLE: THE KEY TO UNDERSTANDING DIFFERENT TYPES OF DEPRESSION

At the end of this chapter you will find a table summarising the typical patterns of the three basic types of depression: endogenous, reactive and neurotic. For ease of reference, I will summarise the main points below.

The different causes

Endogenous depression is caused by disturbances in the structure or function of the nervous system and brain. Depression therefore has an internal origin, and the nervous system is physically affected.

Reactive depression (grief reaction) is precipitated by external events, especially family events. Such an event usually involves a loss that affects the person's future life and well-being.

Neurotic depression is the result of severe difficulties in adapting personality structures. Depression reflects a depletion of tension energy, i.e. when the person can no longer fight to adapt to the stresses of life.

Differences in feelings of sadness

The different qualities and nuances of feelings of sadness can help you to

distinguish the particular type of depression.

In endogenous depression, sadness is characterised by a sense of inner emptiness. The person feels that something is wrong inside. This leads to feelings of unworthiness, guilt and dryness.

In reactive depression we find the same sense of emptiness, but in this case the person feels it outside, in the environment. The feeling of emptiness is associated with the loss they have suffered.

In neurotic depression, sadness, or melancholy, is suffused with self-pity, restlessness and anger at the world. The sense of emptiness is all-encoming, both internally and externally.

Differences in thought patterns

In endogenous depression, the person tends to despise himself, with a strong sense of guilt and despair. He may come to regard himself as the worst of sinners. His twisted thoughts, however, compel him to project blame onto others. Such a projective mechanism gives rise to paranoid delusions.

In reactive depression (grief) there may also be a second-order sense of guilt, if the person believes that he or she is responsible for the loss. As a rule, however, they do not tend to be too self-accusatory; their self-esteem remains largely intact.

In neurotic depression the person sees himself as the victim of his own suffering. Her thoughts affirm that she is above criticism. She demands that those around her devote themselves completely to her, leaving everything else behind. She can also criticise herself, with a kind of tolerant attitude, but usually it is others who are accused. As a result, she has a total distrust of everyone and blames the world for her unhappiness, showing a certain tendency to paranoid thoughts.

Differences in family reactions

Sometimes it is possible to classify a person's depression with a good degree of accuracy simply by observing carefully the reactions of their family .

Endogenous depression tends to induce impatience and irritation in family . This is not a matter of insensitivity, but of a lack of understanding of the phenomenon. Since endogenous depression originates within the brain and the nervous system, such an 'internal' character is usually beyond the comprehension of the family, who are unable to grasp the fundamental problem.

In the case of reactive depression, where the condition of grief results from a loss, the above no longer applies. The situation is practically the opposite. Such a condition raises the empathy of the surrounding people, and the family is always able to understand the grief reaction to a loss. Sadness is something to be expected, and everyone is ready to offer help and comfort.

Finally, in the case of neurotic depression, the family of the depressed person invariably show a mixture of sympathy, pity and annoyance. They can understand the suffering of the neurotic because all of a given family share the same values and similar emotional (and neurotic) reactions in the struggle with life. At the same time it is precisely these similarities that give rise to the conflict. After a certain time, the others have had enough, and they make it

very clear. "Listen, you can't expect to be taken care of forever, so try to realise your situation and make up your mind once and for all to behave differently", or "I already have my own problems, which are not few, without having to deal with yours too".

Other important features also help to differentiate the three basic types of depression. These are set out in the table below, and I suggest you consider them carefully.

VII. GENERAL SYMPTOMS: WHAT TO DO

In the previous chapters I listed various types of symptoms according to the different categories of depression. You may have noticed that it is by no means certain that every depressed person has all the symptoms. Some of them are specific to one or more types of depression. Others appear in every type of depressive state, alone or together with others. Each symptom is only significant within the context of the particular case of depression.

Understanding symptoms restores communication

I say 're-establishes' because the disorder has inhibited the person's way of thinking, feeling and acting, and consequently the patient is no longer 'the same'. In fact one does not "know" him anymore; and therefore it is difficult to communicate with him. A grandfather who used to spoil his grandson, for example, may now look at him with complete indifference. A wife who would normally have responded to her husband's affection with equal warmth may now be unfriendly. There are also other quite peculiar reactions. The person may ignore the greeting of a friend, or may react angrily to the simple invitation to sit down to a meal. But not because he actually wants to act in this way.

A depressed individual is no better able to control himself than a person with a high fever can regulate his body temperature at will. We develop certain abilities to control our thoughts and emotions just as we learn to control our muscles to walk, run, dance or sit down; with illness we can lose this ability to control our physical body. In depression, the person loses their ability to control their emotions and thoughts. Pessimism, paranoia, anger, fear, contempt, easy crying, a tendency to isolate, and so on, are all symptoms over which the depressed person has no control. The normal ability to regulate has been lost, and if you

tell your family member to 'stop crying' or 'pull yourself together', you are merely communicating your disapproval, confirming that he or she is unable to look after themselves. This only reinforces his feeling of being a disaster and a failure.

When you can understand the symptoms, you begin to penetrate the thoughts of the depressed person. It follows that you begin to communicate; and this is the most indispensable condition for dealing with the various symptoms and the illness.

Sadness

Your family member may complain of sadness, deep melancholy; they may feel down, rejected, in a bad mood. This sadness can vary greatly in intensity and shades, from light blue to deep black. But however it may be described, the emotional tone of the person is always below normal.

What can be done

When sadness is only a one-off episode, it may be minor and nothing to worry about. But in real depression it pervades the whole person and is linked to other symptoms. If, no matter how hard you try, you cannot cheer up your family member, distract them or amuse them, sadness is a sign that you should look deeper. You should then pay attention to the presence of other symptoms, which in connection with this may warn you of a coming or already existing depression.

Sleep problems

You may notice the appearance of sleep problems, especially insomnia. If there is restlessness, the person wakes up too early, usually around four or five in the morning, and cannot get back to sleep.

When depression is of the delayed type (slowing down of functions) the patient will only want to doze off, and will sleep all day.

Sleep can also be irregular. The person wakes up, goes back to sleep, wakes up again, and when they get up they will always feel sluggish and not at all rested.

How to deal with sleep problems

If your family member wakes up too early, he/she is likely to fall prey to uncontrollable restlessness. In his own words: 'I just feel unhappy'.

This early awakening presents a double threat. Not only does it interrupt rest and force the person to toss and turn to no avail, with the result that his or her condition gets worse and worse; but there is also the depressive psychic effect of the darkness and loneliness of the pre-dawn hours. You could then fight your own personal battle against insomnia with a programme like this: first try to wake up at the same time as the patient wakes up, so that you can 'start the day' for him. The company of another person helps to dispel the sense of impending doom. Start by preparing breakfast for the patient and bringing any prescribed morning medication. By sitting with him and chatting at the breakfast table, especially if you can show him your enjoyment of this morning talk, you establish communication and get him to relax. He may even be able to go back to bed and sleep for another couple of hours, in which case you will have won a first skirmish against illness.

I understand that it is not easy to provide this kind of help. A high degree of altruism is required of you. But since you are reading this book, I assume that you intend to do everything in your power to do.

If the patient sleeps too much this does not represent a danger in itself. But if this does not lead to more rest, and you feel that sleep is an "escape", it is better to try to limit it during the day. Find something simple to do to keep his attention. Encourage him to stay up a little later in the evening and try to get up a little earlier in the morning. But if all this visibly irritates him, forget it. Too much sleep is the lesser evil. Once he is on the road to recovery and more willing to cooperate, you will be able to get him to change his sleeping habits without too much difficulty.

If sleep is sporadic, medication may be useful (but only if prescribed by your doctor). However, there are some measures you can take to try to relieve tension. Give your child a nice warm bath before going to bed. Read him an interesting book. Put on some relaxing music. There are also some things you should not do if you want to promote a peaceful sleep.

Don't let them read mystery books before going to bed.

Do not serve dishes that are difficult to digest for dinner.

Do not leave the bedroom in darkness; leave a light bulb on at night to prevent fear and disorientation should the patient wake up suddenly. This will make it easier for the patient to get back to sleep.

Do not let the person sleep in rooms that are too hot or too cold. Make sure he/she wears comfortable, loose clothing and does not sleep under a blanket that is too heavy and oppressive.

Appetite deficiency

The depressed person manifests an aversion to food. He fiddles at the table, says that what he is served 'tastes of nothing' and that he is not hungry. Sometimes he can get by with just coffee and cigarettes. In severe depressive states there is a complete loss of appetite, so that the person does not eat anything for days on end. This results in rapid weight loss, two kilos to fifteen within a few weeks; the lack of nutrition in turn aggravates the depressive state.

(Sometimes we are also faced with the opposite problem. Some depressed neurotics may show an abnormal appetite, eating all the time and making trips to the fridge at all hours of the day and night).

How to cope with a lack of appetite

What you need to understand are the person's true feelings about food, which are often quite different from those they have for you. It may well be that the person is hungry, for example, but does not want to acknowledge it. Perhaps this stems from their feelings of guilt and their need for self-punishment. Consequently, if you say to yourself, "Eat something; it will make you feel better," you are actually contradicting the depressive's desire for self-punishment. You become an adversary who does not allow him to suffer as much as his feelings of guilt require him to suffer.

So you'd better talk to him frankly. "Look, I know you're hungry, but you want to make me pay for something. You may or may not be right. But starving yourself does nothing, least of all to solve your problem. We can look together for some ways to deal with what's bothering you. But the most important thing now is that you feed. Come, I'll keep you company.

In this way you have achieved the result of bringing into the light of day the emotional ghosts that haunt the patient's mind, making it clear that you know it is these that interfere with his desire for food. You have made it clear to him that you recognise the existence of his guilt, but at the same time it is not your intention to judge him. In addition, you postpone carrying out the punishment that he sees as 'necessary'. By making the decision to put the food in front of him and explaining the reasons, you have made communication possible. It will not be difficult then for your family member to start eating. And in caring for a depressed person, one victory at a time is the best you can aim for.

Don't always touch the food button

The refusal of food is not always motivated by guilt. Most of the time, on the contrary, it will only be a symptom of depression of the nervous functions. If you harass the person with the subject of food, you will only irritate them and yourself. Look for other ways to stimulate their appetite and get them to eat. Try to find out what her favourite dishes are and prepare them in small quantities but frequently. Show your satisfaction when she eats, but do not comment on what she leaves on her plate.

Another thing. The depressed person is hypersensitive to the appearance of food, as nausea is always lurking. Tempt their appetite with attractive dishes and a well laid table. Suggest, but as if you do not want to give it too much weight, that everyone has a right to be treated well at some point. You may be told: 'I don't deserve it. I am not worth anything. Pretend that you did not hear this and proceed with the meal. Don't be disappointed if, after much effort, what you

have prepared is barely tasted. Put it aside, suggesting casually, "I'll put it aside, so if you want to eat some later.

Sometimes the depressed patient regresses to the point where an emotional block prevents him from even putting food in his mouth. If, however, food does reach the mouth, it is swallowed. It is then a matter of feeding it for a while with patience and firmness.

To summarise, when you feed a depressed person you are telling them that you know that their lack of appetite is a symptom of the illness. You are making them see your understanding of what they are feeling and thinking. You identify with her psychic pain, and such empathy helps her to regain courage. If you can do this, you are already on the right track.

Loss of interest in the environment and loss of the need for gratification

Depression flattens the emotional reactions of the individual, and the normally active functions of the personality become extinct. No wonder then that once vital interests fade and any instinct for gratification is lost.

The sick person has lost all interest in the emotions of life. It is as if friendships did not exist; local, national or international events do not hold the slightest interest for him. The indifference to family and environment freezes him in a situation of isolation and closure. This is the kind of change that most affects people who have always been active in sports, hobbies and social life. Consequently, a wife who comments: 'When my husband misses Friday poker, it means he is really depressed', may be diagnosing her condition better than she realises.

As a spouse, child or parent, or whatever your relationship with the patient, you are part of his environment, and when you find yourself at the expense of his indifference, you cannot help but feel pain. What you have to understand is that the patient rejects you only because the psychic pain he feels leaves no room either for you or for anyone else; the patient can only focus on himself. So if you ask him, "Would you go for a walk with me? I would like to," and this does not provoke any reaction, you are not offended. What you must see is rather the lack of sufficient psychic energy to respond to your request. The fact is that the sick person no longer cares about anything. His sickness leaves him no more room.

How can you awaken the patient's interests and need for gratification?

Your main task is to counteract the symptom of indifference by encouraging the restoration of normal emotional responsiveness to stimuli; and this by the judicious use of your authority (of which, however, affection is an essential component). Methodically and with infinite patience you can lead the depressed person back to his former interests.

In the case of one of my patients, the husband took into consideration the various types of entertainment his wife had previously shown an appreciation for. One of these was bridge, and he decided to start there. One day he told her that it seemed appropriate for her to resume her bridge evenings. With much trepidation and after various objections, his wife was finally persuaded. This first evening was just as stressful for her as she had feared. She barely managed to complete it. Her husband then weighed the benefits he might have gained in comparison with the effort it took to get her to go. Noting that the next day she had shown a little more appetite and a little more willingness to talk, he concluded that every inch gained was worth it, and continued to insist that she come back the following week. He was right. It was not long before his wife began to accept the bridge evenings as normal. Her face and voice became more lively, and there was a hint of zest for life. In the wake of this renewed interest, further progress followed. She became interested again in her husband, in the house, in other social activities, and by then the road to recovery was short.

By pushing her to embrace life in all its aspects again, her husband motivated her to survival. In psychological , her ego-functions had weakened considerably; when her husband took a firm stance on her activities and gave her his in that direction, he offered her a vital thread to hold on to.

I can tell you this. Whenever you manage to animate the depressed person, you help him to recover new reserves of energy. This precludes depression, revives the person's interests, and awakens the need for gratification.

Loss of sexual desire

Along with the desire and joie de vivre, the depressed person also loses all sexual appetite. In people who live alone, this symptom may not be noticeable, but in married couples who have led an active sex life, it soon becomes apparent. When it is the wife who is depressed, she becomes quite indifferent and sometimes insensitive to all sexual stimuli, even if she may submit ively to the sexual act. When, on the other hand, it is the husband's power that is touched, he is frightened, and may develop a considerable amount of anxiety about it. No matter how many reassurances he may receive about the transience of his inability to get an erection, for him this 'proves' that his life is over.

What your spouse can do if there is no longer any sexual desire

Generally, the husband has no difficulty in considering his wife's loss of libido as a temporary interruption due to precise and understandable causes, and in behaving kindly towards her. Such an attitude helps to dispel any possibility of guilt or self-denigration that his wife may harbour at the idea of 'letting him down'.

If it is the husband who is depressed, and this is followed by a decrease or disappearance of sexual desire, the wife's task is more difficult. She may realise, for example, that he is worried about it, but is unable to broach the subject because he feels mortified, whereupon the wife, thinking she is doing the best, tries to go along with him, and for fear of making false moves avoids even touching the subject.

What is required here is precisely the opposite attitude - the wife must find the courage to address the issue openly, reassuring her husband and showing full confidence in a return of his masculinity and unfailing patience while waiting for the healing that will mark the moment of overcoming his impotence problem. In doing so, she must bear in mind that he will be extremely sensitive to every nuance of her words, and that if he insists too much on the subject, he may become alarmed and develop paranoid ideas, leading him to infer that his wife is in fact 'looking for something else'.

But if the latter is sufficiently shrewd and knows how to act with tact and finesse, she will be able to reassure him and make him think optimistically about the future of his sexual performance.

There is also another trap, which if not avoided in time can create a barrier between husband and wife. It is difficult for the other spouse to understand how ardently the depressed spouse desires, despite the decrease in sexual activity caused by the illness, the affectionate exchanges that previously bound the couple together. Even if the depressed person does not respond to the other's advances with the impetus he or she would like, he or she continues to need displays of affection. There would be nothing more inappropriate than the disappearance of displays of intimacy and tenderness in the life of the married couple. Without any substitute object, the depressed person will become certain of having been abandoned. And when such a barrier of coldness is set up, it can be more harmful than depression itself, because it can persist for a long time, and later it can make the resumption of normal and uninhibited sexual activity much

more difficult. Expressions of affection cannot be allowed to dry up. On the contrary. The displays of affection must continue as a conduit until sexual intercourse has become an integral part of the couple's life again.

Neglect

The depressed person will often be inclined to neglect his or her appearance, personal hygiene and social behaviour. One of the most obvious symptoms of depression is usually a sloppy and neglected appearance. If he is a man, he will neglect to shave, and he won't even bother to smell or wash. If it is a woman, she will continue to wear the same stained and tarnished dress for weeks on end, will not put on make-up, will not bother to comb her hair: and she too will neglect her hygiene to the point of stinking. Soon these people are only vaguely reminiscent of the meticulous individuals you knew before.

What to do if this tendency to neglect appears

You have to take charge of the situation, and monitor the person closely. Be as frank as possible. Hints are not enough for the depressed person who wallows in neglect. It is a symptom of considerable regression, and your task will be to treat it with the attention that one would give to a child. You will have to tell him clearly and explicitly when he has to bathe, brush his teeth or comb his hair. You will have to get him out the appropriate clothes and if necessary assist him while he gets dressed. Don't hesitate to correct neglectful behaviour at the table, or other behaviour that embarrasses those around him. All this, however, should be done without impatience and with the utmost gentleness. The firmness of your words must not prevent you from expressing in your voice and facial expression all your affection and care for the sick person.

You might think that a 'policy' of this kind can only have negligible results in

relation to the problem of disease in general. Not at all. By contributing to the maintenance of your family member's outward appearance, with all the advantages that civilisation brings in this respect, you will help him to retain the respect of others despite his depressive state. After all, illness is already a serious enough threat to the state of family relationships, and it is hardly appropriate to add to it the effect of bad smell and unpleasant behaviour. Your vigilance becomes a factor in moral reconstruction, which at the same time helps the depressed person not to sink into self-loathing. that your family member will one day get well, and by being there for him with this kind of supervision you help him to maintain his social status, sparing him embarrassing memories of the time when he was ill.

Loss of self-confidence

Each of us lives at a different level of self-confidence. In your case, for example, you may have a sister or niece in her early twenties who until recently had always radiated poise and self-confidence. Suddenly she has started to show insecurity. She can no longer make appointments, and feels uncertain about her office work. She lets herself go a little, and clearly neglects her appearance. Her confidence fades away. You have never seen her like this; you try not to take it too seriously, but at the same time you wonder whether you should do something about it.

What you can do if your self-confidence has been lost

In the presence of this symptom, what one must absolutely not do is to tease the person about his ineffectiveness, or to catechise him. Ignoring the problem will not help either. Something is wrong, and the problem must be addressed.

Tell her frankly that you have noticed a noticeable change in the last week (or

month) and that you know that such a state of insecurity and depression is a hard test. But do not encourage her to feel sorry for herself. What you need to say is: 'Here, let's say you can't do your job as easily as you used to. That may be true. But look at the things you can still do. What might they be? Invariably, the depressed person will answer: "None, now. Neglect this statement, and enumerate the situations in which he continues to prove himself in spite of his growing distrust. You must insist on this line without ever becoming discouraged, because renewed self-confidence is a building that must be built stone by stone, day by day.

I a young lady who kept lamenting her inability as a wife and mother. Suffering from neurotic depression, she insisted on the subject of her uselessness and incapacity. She had always had a tendency to go into crisis over the smallest problem, whether it was a breakdown in the hoover, a parcel that was late in arriving, or scheduling a house painting in the spring. Fortunately, her husband was an intelligent man who quickly grasped the spirit of my advice. I note the way he approached the problem, as an example to follow in the art of restoring self-confidence. The fundamental principle he followed was: Praise the person's efforts, and nip doubts in the bud.

Instead of deploring his wife's neurotic attitudes, which were now more pronounced than ever, he encouraged her pleasant traits, focusing on the resources that continued to work to her advantage even after the onset of the illness.

When she would call him at the office, sometimes at hourly intervals, for reassurance, or when she would continue in that tone once he had returned home, her husband would counter: "But you did go to take the children to school this morning, didn't you?". "Yes, but...". "And yesterday?" "Yes...". "And the day before, and for the whole week?". "Yes." "Great. And then it seems to me that you've also cleaned the house, because I can see everything pulled together." "Yes, but not like...". "And then you also went shopping, buying everything you needed, didn't you?". "Yeah, but..." "And you cooked this delicious dinner?".

"Yes, but it's not....". "You're doing a great job. That's what counts." Whenever and whatever the situation, no matter what his wife's objections were, he barred his doubts and fears.

In helping the depressed person who has lost self-confidence, it is therefore essential to focus on gathering strengths and minimising weaknesses. In the case just described, the husband gradually conditioned his wife to take into what she could do, shifting her attention from what she could not do, until she was able to use this mechanism to her own advantage.

I it that this continuous attention to the patient's manifestations may be fatiguing and ungrateful; but it is no more so than that which must be paid to an invalid who has to follow a particular diet, has to be washed and dressed, and so on. This is all the more so if it is someone close to you. The decision is yours, but when you help a depressed person to acquire new patterns of adaptation you are at the same time rewarding yourself, because you are also doing something else - you are helping to prevent future episodes of depression in that person.

Loss of self-esteem: variations

If a normally productive and self-confident person begins to doubt his or her own worth and despise themselves, it can be said that the individual is almost certainly depressed.

Self-esteem is something different from self-confidence, although they are closely related.

Self-confidence is the measure of our sense of adequacy with regard to what we

have to do.

Self-esteem defines what we think of this adequacy, or capacity, and consequently what we consider to be our value. It is the image we have of ourselves.

If we act with self-confidence, self-assured, our self-esteem remains unchanged.

But when the level of confidence and security of our total personality has fallen too low, and we cannot rebuild it quickly enough, our pride is hurt. It is at this point that our self-esteem also disappears, leaving us with a negative image of our personality.

In endogenous depression the person loses all pride and self-respect. The sufferer feels that there is no longer any part of his self that can be considered of any value. He is overwhelmed by feelings of guilt and total unworthiness; he feels condemned.

In reactive depression, where the specific cause is a loss of some kind, selfesteem may remain intact as far as the person is concerned; rather, the sense of emptiness is felt in the environment, and the patient has the feeling of living 'suspended in a vacuum'. If, however, the reaction to the loss gives rise to feelings of guilt and a progressive loss of all hope for the future, self-esteem will also be affected in parallel.

In neurotic depression, self-esteem comes and goes. Sometimes there may be manifestations of conceit and arrogance aimed at attracting the attention of others. But when you see that this type of behaviour alternates with moments of

despondency and almost grotesque humility, you realise that the person is above all frightened and depressed, and is asking you for help.

What to do when self-esteem disappears

In the preceding pages, I mentioned that self-confidence can be rebuilt by focusing on the actual achievements of the depressed person in everyday life. This technique, however, does not also have a corroborative effect on selfesteem; once self-esteem has disappeared, a state of complete despair sets in. At this point depression can be diagnosed as severe. If you try to reassure the person that he or she can cope with completely normal tasks, you will get nowhere. There is no such level of normality at this stage, and your encouragement will not elicit any reaction.

In order to reactivate self-esteem, you must instead appeal, directly or indirectly, to the person's rational faculties, emphasising the logical contradiction of his or her self-disclosures. Look for past situations that the person has dealt with adequately, and compare them with these. The trick is to get the person to value what he/she has managed to do before the depression. Your aim here is to get the person to overcome the state of despair, which in turn denotes suicidal ideation.

ionate talk about 'what an exceptional person you have been, are, and always will be... we all think you are great' must be avoided. The depressed person will consider these - and rightly so - empty words and reject them. What you need to do instead is to point out to him how unreasonable his ideas about himself are in the light of his personal resources and abilities. Enumerate them (everyone has them). His achievements may be in the field of work, raising children, certain manual skills, a name earned as a collector or chess player, a reputation as a trusted friend, gardening, or anything else that applies to the individual case. To give more weight to your words, reaffirm them in writing and hand the paper over to him. Every time the depressed person falls back into self-denigration, insist that he or she re-read what you have written. Even if you don't notice any

immediate reaction, you will soon realise that he or she has started to study your words and think about them.

In addition, get friends to your efforts. Get a neighbour to ask your family member for advice on certain repairs to his or her house. Have someone come and ask their opinion on a child's education. Or ask a friend who shares his interest in gardening to solicit his appreciation for a successful hybrid. Whatever the field of expertise in question, be sure that it is a subject in which your family member is particularly knowledgeable.

In this way you build up a model of the strengths of his personality and let him test the validity of them. As the coherence and solidity of this model is acquired, the elements of judgement which form the basis of self-denigration take a back seat. Your value judgement of him, like that of others, begins to take the place of his own, until you get him to take it up fully. In this way he will have acquired a more rewarding self-image.

Will healing be achieved? This type of approach is not enough on its own, but over time it has the effect of improving the state of mind, and in conjunction with other treatment methods it consolidates the healing process. Once the depression has been completely overcome, the normal level of self-esteem is restored. But in the meantime you will have helped to mitigate the suffering and sense of degradation that accompanies the loss of self-esteem.

Concerns about body functions

I have already mentioned how the depressed person tends to focus on his or her body, complaining of pains and aches of various kinds, but always rather vague; the family doctor, no matter how many checks he or she makes, cannot discover any particular organic disorder.

However, the doctor may have told you that your family member probably has 'functional nerve disorders'. These words have puzzled you. What does the word 'functional' mean? Is it less worrying than 'organic', or does it indicate something worse? And what can be done about it?

It will therefore be appropriate to explain this term as it relates to depressive illness and the nervous system.

What does 'functional disorder' mean?

Think for a moment about yourself and your normal reactions. Have you ever considered the fact that when you experience an intense emotion, whether unpleasant or pleasant, it is accompanied by certain physical changes? To give you an example: have you ever 'laughed until you felt sick?' I'm sure you have too. While laughing, you have doubled over, your cheeks and jaws ached, you could no longer breathe, and you had to bite your lips to calm yourself down... Your heart started beating wildly, and you almost 'fell into your throat'. You "almost had convulsions". These are but a few of the symptoms of the emotional reaction called 'laughter'. And all of them are functional.

In the same way, an opposite reaction can result in a functional symptomatology. You may have been confronted with a situation that was so disgusting and nauseating that your stomach 'turned inside out'. You may even have felt a real sense of nausea. You felt your heart beating fast, your breath short, your arms weak and limp, and you felt drained of energy. You felt a sour taste in your mouth, and you felt dizzy and your scalp flushed.

Think now of the various kinds of emotions, and you will find that there are

times when you are breathless with joy, blushing with embarrassment, trembling with anger, dying with boredom, shivering with fear, vibrating with excitement, and so on.

These symptoms are, in a nutshell, organic functions that go hand in hand with the perception of emotion. If you were given an electrocardiogram or any other test while 'laughing until you feel sick', your heart would reveal nothing abnormal. Similarly, you could x-ray the stomach of a person whose stomach 'turns' in disgust, and the result would be identical. Disorders such as 'feeling sick' from laughter or a 'turned-up' stomach are therefore called 'functional'. Sudden changes of this kind in the functioning of the organism are not in themselves organic disorders, and they last, or 'work', as long as the emotion lasts.

This is also true of depression. The physical symptoms that accompany the kind of emotion that constitutes the depressive state work with the emotion and because of it. Consequently, they are functional symptoms; as physical manifestations they represent the temporary disorganisation of nerve function that underlies depression. When the depression is overcome, the organic symptoms are also overcome - just as the accompanying physical symptoms disappear as laughter or disgust cease.

I list below the physical symptoms most commonly complained of by the depressed person, and which constitute the functional part of the depressive disorder:

Headaches.

Burning sensation or tension in the head or neck.

Dizziness or weakness.

Palpitations or acceleration of the heartbeat.

Blurred vision.

Loss of control over the body; coordination difficulties, tendency to drop objects and bump into fixed obstacles.

Difficulty breathing, stiffening of the ribcage - 'I can't take a deep breath'.

Constipation or diarrhoea.

Tension in the urethra.

Pain in the abdomen (colic-like).

Heartburn or nausea.

Stomach contractions, or a feeling of 'blockage' at the mouth of the stomach.

Oppression or pain in the chest (which the person often takes for 'heartache').

Pain and cramps in the legs and back. Excessive sweating.

Itching or a feeling of 'goose bumps'.

General weakness; tremors.

How to deal with the patient's concerns about these disorders

The depressed person's insistent complaints about the seriousness of his or her physical ailments may eventually lead you to think that something is wrong. You will then have to summon up all your courage to believe the doctor when he assures you that your family member has no heart (or lung or digestive) ailments, or any other physical ailment.

However, by accepting what the doctor tells you, you must not fall into the opposite error (which frequently happens). When your family member grumbles about his or her heartburn, you must not tell them that their illness is only mental. That is not true: their ailments are in their stomach. Of course, it is something functional, and not a real disease of the organ in question. The complaints, however, do indeed refer to an unpleasant or painful sensation, since the same imbalance of nerve function that gives rise to depressive disorders also produces such functional disorders at the physical level. There is no significant difference here from the disturbances you may have experienced yourself following a fit of fury. The pain was in the body, not in the brain! And when you

were able to control it, it disappeared; similarly, the complaints of your family member will disappear as the depression subsides. This is why all your sympathy and empathy is required.

Instead of dismissing the complaints as purely imaginary, it that they are real, but remind your family member that they are most likely due to depression. Make him/her take the medication that the doctor has prescribed: it is not unlikely that he/she has neglected to take it. Why? Perhaps because of that psychic need for self-punishment I mentioned above. "I don't deserve to be well, so I don't want to treat myself": this may be the patient's reasoning. Or the physical symptom may be a kind of SOS used to draw your attention to his real suffering, i.e. the psychic one.

With all this in mind, there are certainly some measures you can take depending on the specific case. If it is digestive problems, prepare light meals; if your family member complains of leg cramps, massage his limbs. If he has excruciating headaches, have him lie down and apply a cold compress; and if he has chest blockages, have him breathe deeply and regularly while you count to a hundred. The blockage will be relieved.

All of these are of course only expedients, but in the eyes of the patient they will be demonstrations of the love and attention he so desperately needs. If you spare no effort in this respect, the complaints will tend to diminish, and even the depressive state will be temporarily relieved, because the patient will feel that someone is able to understand him.

Lack of ability to concentrate

The individual with this symptom is no longer able to take any interest in work and life in general. The technical term for this condition is reduced attention

span. The person is unable to read a newspaper, go beyond the headlines, or follow a full programme on the radio or TV. If you ask him a question he may be able to understand it, but answering even a yes or no question is an almost insurmountable effort. At a more severe stage of the illness the person seems to be completely lost with the mind; he grasps the sound of your words, but lacks the ability to grasp the meaning, as the psychic constraints of the depressive state prevent him from absorbing the message. The words no longer .

What to do when the depressed person loses the ability to concentrate

It is essential to maintain with the patient.

First. You have to bear in mind that when there is a lack of concentration the person is confused even by the normal fluctuations of the environment (sounds, atmosphere, movements and so on). They become unable to maintain a grip on their relationships with things and people. Consequently, you must frequently reassure your family member about this, without waiting to be asked. Obviously everyone will find their own form, but the content of your speech should go something like this: 'Don't worry. I am and will be here for you, so don't hesitate if you need to talk about something, whatever you have in mind. That's why I'm here. These kinds of reassurances serve to absorb the little knocks that are continually brought to him by the impact of the confusing reality around him, and help him feel more secure.

Second. When talking to him (or her) always stay within his (or her) field of vision. Do not do it from another room, or from a place where you cannot be seen. Make sure that you are always facing the person, so that they can observe your every move, and try to look them in the eyes. This serves to stabilise their attention, and to help them connect the substance of what you say with what they see. This is a visual aid to force their consciousness to your words.

Third. After asking a question or making a comment, wait for his reply. Stifle any impulse to rush him. Give him a full minute if necessary (and maybe check your watch, because sixty seconds can be very long if you are impatient). Once you have managed to get an answer, the next ones will be more ready: as your concentration improves, you will find it easier to hold their attention. It is then time to involve the person in some task that can be done in your presence. At the same time keep the conversation going. The longer you can keep the verbal exchange going, the better results you will get.

If at some point the person seems dizzy and unable to continue talking, do not insist. Let an hour or two , then start again. Each success of your efforts will make it easier for you to try again; gradually your attention span will become wider, resulting in greater mental clarity.

Inability to concentrate is usually accompanied by poor memory, and very often these two symptoms must be treated as one.

Memory disorders

You may be puzzled by the fact that your family member has absolutely no recollection, no matter how hard he or she tries, of a visit that took place even a week ago, or of a trip to the seaside that you all took together just last summer, or of your parents' golden wedding last month.

The causes of poor memory are similar to those that result in an inability to concentrate. Memory blocks and the inability to concentrate result from the inhibition or depletion of psychic energy reserves. I dwell on this point for a specific reason, which relates to the time when your family member is cured of his or her illness. When the doctor tells you that the patient is to be considered cured, you may be surprised that the person does not retain the slightest memory

of things that happened during his or her illness. Why? Does this mean that he is not completely cured? Not necessarily. The gaps in memory are probably due to the fact that during the period of depression the person was unable to concentrate, and consequently throughout that period his 'memory circuits' functioned in a defective way, preventing the memories from being deposited. He cannot those events because they have never been recorded in the brain.

How to cope with memory disorders

Again, you will have to use all your patience. Of course, saying it is easy, but doing it? It is understandable that you might ask such a question, but if this symptom alone is enough to exasperate you, perhaps you should start asking yourself serious questions about your ability to care for your depressed family member.

Suppose you happen to mention a recent event at which he was present. It seems, however, that no trace of the event remains in his memory. It is as if nothing had happened. "What the hell are you talking about?" he asks, shaking his head doubtfully. If you become impatient at this point, you scold him: 'How can you not ? That time we went with Uncle Joe, and we got a dented wing in the car park!", you won't be able to generate the slightest spark of memory. On the contrary, you will suppress any possibility of doing so, because by challenging his memory in this way you will make him feel, even if unintentionally, ridiculed, and convinced that his condition is much worse than he is told, and that he is probably losing his mind. One look at his sorrowful expression is enough to make you feel remorseful; and such negative emotions can be spared to both of you.

Instead, act in this way: avoid reprimands, and bring the person back into with the facts.

Tell him that you understand that he may have memory problems, but that these will be resolved positively in due course. In this way you will be sending a simple message of understanding and communication; and by stating the symptom of the memory problems you will at the same time make it clear that you accept them. At this point you will have gained his interest. Go on more or less like this: "I imagine that when they dented our wing you were probably so engrossed in your thoughts that you didn't notice. And that's why you can't . But listen to what happened that time". You proceed to recapitulate the details of the incident, making sure that you tell him a story of which he is completely unaware, because in fact that is exactly how it is.

On another occasion, the talk may be about a trip you took together, which now escapes him. You may be tempted to insist: 'Don't you ? It was when we met the Browns, and went to dinner with them at that restaurant by the sea...'. At this point, however, the person is so confused that they no longer have any idea who the Browns are, and their interest in food is so low that it does not matter whether the restaurant you are talking about was that one or any other. When, as a result, you see that the memory does not come back, put it this way: "On the last trip we took, we met some people - the Browns - and went out to eat with them", and go on recounting the events in a relaxed way, as if you were telling an entirely new story. As you speak, your family member will listen, they will be able to enjoy your story, and you will be surprised how much of it they will later.

If you pave the way for him in this way, you will probably see that at some point he will start to take part in the conversation, perhaps hesitantly: but it is still a start. So try to offer him further ideas, and follow the progress of a renewed attention. The problem is far from over, and it is likely that he will suddenly get stuck on a word or a name when reporting something. Try to get him over the hurdle, but use the utmost caution, and never too explicitly. Or he may make a mistake and stop talking. Avoid pointing this out. Allow him some inaccuracies. At this point he is so sensitive to the possibility of making mistakes that if you go too far in offering your help you may embarrass him. Your task is to revive

his memories, and consequently reactivate his memory functions. For this purpose, you have to use very subtle suggestions. In the long run this kind of approach loosens the constraints of the depressive state and builds a bridge to memory recovery. You must therefore consider it a great progress that your family member simply returns to participate in the conversation; at this point a barrier will finally have fallen between you and him, thus facilitating his rapprochement to a normal level of interpersonal relations that allow him to feel once again part of a community.

Inability to make decisions and use will power

Because of the depression, your family member will in many cases be unable to make up his or her mind about even the smallest things. If, for example, he/she has to attend an evening event, the first obstacle will be: which shoes (or which suit or tie) to wear? If it is a woman, she will go from a blue dress to a green dress to a black dress, then back to a blue dress, and so on, totally unable to choose. In a restaurant, people with this kind of depression are shocked at the mere idea of having to order one or the other of the dishes on the menu; it becomes a problem even to decide whether or not to salt the food. In the course of the day, if there is a choice between two alternatives, these people will reject both rather than accept one of them. This emotional attitude may explode into fits of rage if others fail to the decision. The feeling of depression is then aggravated and the person may abandon almost all hope of recovery.

Loss of willpower may be related to this type of chronic indecision. Sometimes family label both symptoms as neurotic attitudes that the person could overcome 'if only he wanted to', or that should be cured in and of themselves. But such an assessment is inaccurate. In most depressive states, the inability to make decisions and the loss of willpower are not simply personality weaknesses, but symptoms of the primary depressive disorder. The person will continue to experience these symptoms until the depression has been treated and recovery has been achieved.

What to do about indecision and lack of willpower

The dramatic change that you see in the person in whom these symptoms occur may shock you, especially if it is someone who has always played a positive and decisive role in life. However, you have to think that as a result of the depression, the decision-making mechanism is practically blocked; it is natural that you cannot 'see' this blocked situation, because this mechanism is hidden in the brain chemistry. On the other hand, you have to think that the centres which preside over the faculty of decision-making are only temporarily excluded, a bit like a wrist may be temporarily out of use after a sprain. Your task in this case will be to take personal responsibility for decision-making in its place.

Do you the story of the donkey who starved to death because he couldn't decide which pile of hay to eat first? I can't tell if the donkey in question was depressed, but your family member is. And so, if the problem for him is to choose between orange juice and tomato juice, don't leave the choice open to him. You make the decision, and he will agree. Similarly, if he can't decide between a sports shirt and a dress shirt, you make the decision: hand him directly the clothes you consider appropriate for the occasion. You cannot know how relieved he will be to accept your choice! You will not even have to ask him whether he would prefer to go for a walk or visit some friends. Plan it yourself, and he will follow you without question. If he is left to his own devices, he will be torn apart by uncertainty, and this must be avoided at all costs. As he proceeds on the road to recovery, this kind of incapacity will disappear, and he will again be able to choose for himself.

Poor judgement

Here you must adhere to the following fundamental principle: you must not trust the depressed person's judgement at all. that the normal equilibrium

of the nervous functions has ceased to exist in him; and consequently his thinking is distorted, and he is no longer to be trusted. In the case of the depressed individual, the respect and attention that is due to the judgment of others is completely out of place. Such a person is sometimes subjected to the most frightening pessimism, and will frantically search for a way out of this state of despair, using the most cerebral motives: she will tell you with ionate conviction that the only thing that can really make her feel good would be to liquidate her business, and to be finally free from the responsibilities that this entails; or to sell her house and move somewhere else; or to divorce... Only then will the depression go away. If, by chance, the family gets involved and such initiatives are taken, it soon turns out that not only has the depression not automatically resolved itself, but that it has actually worsened, because now, in addition to the burden of the illness, the person must also bear the burden of having cut off his or her usual moorings. And invariably, once the depression is over, he will take it out on his family: 'Why did you let me do that? Yet you knew I was ill... you should have stopped me, even if it meant tying me up".

What to do about poor judgment

Those who have been through more than one episode of depression and have been able to reflect on it with sufficient clarity, know that on such occasions they cannot trust their own judgement. Whatever the field of his activities, he will try to be as cautious as possible, and not to find himself having to take important decisions until the episode is over. But this is not a frequent occurrence. Usually it is the family that has to take on certain responsibilities. This is why your intervention can be of decisive importance in the case of a family member suffering from depression. I can understand that you are reluctant to take on this responsibility. But if you are frightened of it and back off, hoping that an inspiration will come from heaven to enable him to cope with his problems alone, you are doing him an injustice. Then what his judgement may induce him to do may prove to be a disastrous mistake that will oppress him for years.

An example, in which the decisions of a 24-year-old mother suffering from

(untreated) postnatal depression were accepted as good by her parents. It did not even occur to the parents that her judgement was being affected by a hidden depression. Her husband, a weak and rather stupid man, unprepared for marriage, had been ready to leave her for a long time, and when his wife fell prey to depression, he took the opportunity to obtain a divorce. Apathetic at times and agitated at others, she agreed to his request for custody of the child. Her parents expressed their misgivings, but she forbade them to interfere. "You have nothing to do with it," she shouted. "I know what I am doing. Intimidated, they backed down, silencing their objections on the matter. In the absence of medical treatment, it took her almost a year to overcome her depression; but when she came to grips with the loss of her child, the blow was so great that it caused a relapse; and she continued to teeter on the edge of sanity until the need for psychiatric treatment was recognised.

It took another year of legal wrangling before the child was returned to her care. Her defective judgement had set in motion a chain of events that could not be remedied until everyone, including the court, recognised that her judgement had been temporarily impaired by her condition and should not have been taken into at the time.

In another case, a 48-year-old postal worker suffering from severe diabetes (requiring daily insulin injections) suffered his second episode of manic depression. This time paranoid delusions were also evident (see Chapter IX); at one point he began to refuse insulin injections, claiming they were being given to 'dry out his brain'. None of his family dared contradict him, until a severe diabetic coma necessitated emergency hospitalisation. His life was in serious danger and he needed two weeks of intensive care to restore his diabetic condition. This organic trauma could have been avoided if due consideration had been given to his aberrated judgement.

Families of patients who go through multiple episodes of depression have the opportunity to learn from the hard experience. I a man who was subject to episodes of depression that recurred every four or five years. He was

the owner and manager of a small grocery shop in a good location, from which he earned enough to live a carefree life. In the first two episodes of depression he showed typical feelings of unworthiness, guilt and self-condemnation. On both occasions, he had sold his shop for far less than it was worth at the onset of his depression, believing that the root of his depression was the excessive pressure of his work. After his recovery, he had to recognise the fallacy of his judgement and bought back the shop, obviously at a loss.

On the third episode of depression, when he again started talking about selling the shop "once and for all", his wife wasted no time, found someone to run the shop, and arranged for him to get immediate psychiatric treatment (instead of waiting and hoping the depression would go away on its own).

When the faculties of judgement are impaired, the primary need is to protect the interests of the depressed person. Not that this is always an easy task. The depressed person will explode in furious objections, go into a state of frenzy, and resort to insults and threats. However, you must remain firm, because when the patient is cured he will thank you for what you have done. "I think I didn't realise what I was doing. Imagine what a mess I would be in now if it wasn't for you". These are phrases I have heard countless times.

Agitation

In the presence of this symptom the person may present various degrees of hyperactivity; but restlessness and tension are always predominant. He will not be able to sit still, he will walk hither and thither, he will go from one room to another, he will stop for a moment to look out of the window (but without seeing anything), then he will force himself to sit down, but only to get up a moment later, and he will start doing one thing after another without being able to finish one. I think that if you were to give a definition of the state of your family member in a situation of total restlessness, you would describe it as 'very nervous'.

Such people, depending on their degree of agitation, may speak of 'a constant gnawing inside', of 'a beast standing here', of a particular sensation in the pit of the stomach, or of an 'iron band' tightened around the chest. The usual noises of the house make her jump. When you try to strike up a conversation they will not pay the slightest attention to you, because they are so engrossed in their nervousness that they are unable to notice anything else. Such agitation never seems to subside. The person asks for relief and hope - "But will I ever get well? When do you think I will get out of this?

THOUGHT CAN ALSO BE AGITATED. I wonder if you have ever tried to imagine the tumultuous state of thoughts that occupy the head of the depressed person in a state of agitation. From his appearance and actions he appears to be tortured without respite by his own thoughts, imbued with feelings of guilt, worthlessness, anger, fear and resentment, and the feeling of a fearful and impending doom. These anxieties can reach such proportions in the mind of the depressed person that he may desperately seek any means of escaping them (see the last paragraph of this chapter, 'Rising tension ... a warning sign').

What to do when the person is agitated

Your natural reaction might be to intervene in the apparent reasons for his agitation. Let's say your family member is brooding incessantly about certain issues that are nagging at him, such as the fact that he should have accepted that job offer fifteen years ago: then things would have been different; or that he made a serious mistake with his son by not insisting that he study law; or that he ruined his sister's life by not opposing her marriage to a man of a different religion from his own.... To your eyes, these are obviously absurdities, misplaced concerns, and you may be tempted to discuss them, suggesting that perhaps the job was not so promising, that his son might not have the right qualifications to be a lawyer, or that in the end his sister's marriage did not concern him; and that in short, all his recriminations are without rational basis.

I would suggest that you do not embark on such an enterprise, because you have very little chance of success. Within the framework of the depressive state, the depressive's feelings of guilt are real and his worries are entirely valid - for him. It is his disturbed nervous system that produces this gloomy view of life, and questioning his arguments will not change his mental connections one iota.

From a constructive point of view, however, there are several things you can do in order to calm his agitated state.

Take it with you into a quiet room, turn down the lights, and put on some relaxing music at a low volume.

Limit visits as much as possible; quiet solitude can be beneficial. Measures of this kind remove excessive stimulation, which can lead to an increase in the level of tension. In short, you need to create an oasis of tranquillity and calm.

Speak to the patient in a calm and quiet tone. Explain to him that you are aware of the thoughts that may be troubling him. If the agitation is serious, he may sometimes turn on you in a fit of rage, shouting at you to go away. Do not be discouraged. Things will change. Make it clear that you know exactly how he/she feels, but that you are sure that he/she will get through this. And add: but it would be much better if you could somehow talk about it.

Little by little he will realise that he can trust you, and will begin to tell you in words his state of grief and despair: if not on the same day, then on the next. If not on the same day, then on the next day. Once this has happened, his inner turmoil will be calmed down and he will be able to achieve relative tranquillity. The next time, you will then find him more amenable to your offers of .

But what is more important is that you will have achieved your aim: to distract him from himself and his worries.

Depending on the time of day and circumstances, then look for other opportunities for distraction - a slow walk in the park, a shopping trip (short and uneventful), a short visit to a friend or a cinema (perhaps an afternoon show at a venue with not too many people). Or you can organise some undemanding activity that will reduce the level of agitation, such as rearranging a kitchen cupboard, tidying the attic or washing the car. You must not expect the agitation to vanish instantly, because it will return, and this until the depressive state has been overcome. But by favouring these even temporary returns to tranquillity, you help to rebalance the nervous functions, and keep depression at bay.

I would like to talk about a wife who is devoted to her husband far beyond the call of duty. The husband could be described as a 'captain of industry', subject to recurrent mild episodes of depression. With the help of medication and psychotherapy he manages to overcome these episodes with relative ease. When he falls prey to depression, however, the predominant symptom is agitation. In the last episode his wife followed some of the suggestions I have just given you. But she did even more. Knowing that in this phase he tends to deplete his energy reserves by demanding too much of himself, she began to make lunch appointments with him outside his office, two or three times a week.

At first her husband objected. How could he leave his desk, with all the work to be done? And what would happen to his working relationships, which took place every day during lunch? His wife rejected every objection, and he finally agreed, "but just this once".

That 'just this once' has now become part of his routine. Before meeting him, his wife jots down snippets of conversation collected during the day that he might appreciate, and scours the newspapers for news that might pique his interest. The hour at the table may become an hour and a half or two. Then they go for a walk

together; sometimes they go shopping or visit a museum. She regales him with her anecdotes, and in this way he becomes interested in her (and not just in himself). These intervals are now a great source of relief for him. With the of his wife, who in this way helps him to contain the pressures and tension to which he is particularly sensitive, his agitation is kept to a minimum in the course of each episode, until he is completely back to normal.

Crying and ease of tears

These two symptoms are fairly common signs of depression. The person suffering from a sluggish depression will cry quietly, or go off into a corner sobbing. She wants to be left alone with her own tears.

The agitated depressive will start crying without warning, sometimes in hysterical tones. Your attempts to console him will be to no avail. In the case of severe agitation, he will sob about his alleged faults, repeating: 'I'm no good, there's nothing to be done', or 'I'd rather be dead. I don't deserve anything, I'm a failure!". He may even beg you to kill him, to take away his despair. And it is not just a matter of gimmicks to attract the attention of others. Crying is genuine. It expresses a state of unhappiness and despair.

In certain cases of depression the patient is not easy to cry, on the contrary. The person may say: "I would like to cry, but I can't. I'm sure if I could cry I would feel better. I am sure that if I could cry I would feel better.

How to treat the symptom of crying

If you are a sweet and sentimental person, you probably cannot stand the sight of

tears. The crying of your sick family member makes you feel bad. However, when tears act as an emotional release valve, they can be encouraged. Especially in the case of a grief reaction; when the person has suffered a loss, tears flow easily, and serve the function of a healthy release of compressed emotions. Tears then momentarily 'wash away' feelings of depression.

However, when a bout of crying just won't go away, and is accompanied by extreme agitation and self-defeating gestures, it's time to call a halt. Let me tell you how you can end almost every crying fit by using a simple psychological trick.

Sit down in front of the person, and tell him or her: "Go ahead and cry if you want to, but look me straight in the eyes. It is a fact that it is not possible to continue crying while looking another person in the eye; and if your family member does what you say, the tears will stop. This may not necessarily happen immediately; he/she may look away and continue to cry. Take his or her hands in yours and ask them to look into your eyes again. You may have to repeat the invitation several times, but eventually his gaze will rest on yours, and the result is practically certain; the tears will gradually dry up, and the person will perhaps begin to talk about what is causing him so much pain.

Whenever you manage to shorten a crying fit at the same time, you limit the waste of energy, giving the depressed person a chance to preserve the strength to fight the disease.

Anticipatory anxiety

The personality of the depressed person functions within a narrow emotional margin. The rational faculties are blocked, and every event puts the person in a state of alarm. He is continually worried about what may happen at any moment

in the future. This attitude is called anticipatory anxiety. It is not possible to appeal to the patient's "common sense", because during the (severe) depressive episode he has regressed too much for his usual level of intelligence to be of any help. Expecting him to plan or prepare future activities is very unrealistic. It is too difficult for him to anticipate events rationally. His sluggish and inhibited nervous functions cloud his vision of tomorrow. Sometimes he is so obsessed with despair and obsessions, with guilt and the psychic pain of the moment that he cannot even emotionally anticipate what is to happen in an hour's time.

If, therefore, a certain future event imposes itself on the consideration of your family member, it can be a serious blow to his nervous system because he simply cannot cope with the effort required to identify with the problem. In his present state any future event, however insignificant it may appear to your eyes, means trouble.

How to treat this type of anxiety

Often you can get around the depressed person's premonitions by having them limit their awareness to the present moment only.

If, for example, you happen to tell him that you are planning a holiday for him when he is well, and he says in a plaintive tone: 'No, no, I'll never be well enough... forget it, it's not worth it,' you drop the subject, only to take it up again when the time is right. Or you may have to announce that a niece of his is coming to visit him next week, and the depressed person may become very agitated and irritated. How will you entertain her? Maybe she expects to be taken care of. And he may add, in a belligerent tone: 'You know I can't stand her, I never have' (which is not true), sometimes pushing his agitation to the point of paroxysm (and it becomes clear that he is looking for a fight at all costs). So announce the arrival of the guest just before he comes. This prevents the accumulation of anxiety, and the person will be in a better condition to welcome you.

On another occasion someone may bring up the subject of a family celebration a few weeks in advance, in the naive hope that such a prospect will cheer the sufferer up. A depressed patient of mine, informed that he and his family were going to a wedding, commented acidly: "Why the hell are they getting married? Isn't there enough trouble in this world?". Avoid dealing with such topics in advance. The more cheerful and festive the occasion, the harder it will be for the patient to confront his state of despair. When the day arrives, it may be that the depression has been overcome, it is that the person is able to participate joyfully in the event; otherwise a wedding is no place for her.

Family often make the mistake of comparing the depressed person with the future. If you could observe the situation from the outside, as an invisible witness, you would find it hard to believe the havoc that their intemperance wreaks. With their discussions on the subject they obsess the patient for weeks. Family life is turned upside down, as if it were a matter of life and death, and the depressed person becomes distraught without the others being able to perceive the damage they are doing to him. If they could only keep quiet and not mention the subject until the right moment comes, the problem would solve itself. The following principle must be adhered to with the depressed person: deal only with the present, do not test him with tomorrow.

Fear of loneliness

It is disconcerting to see people in such a situation who have previously always been brave and full of adventure.

Suddenly the person becomes fearful about things like taking the bus, or driving alone across bridges and tunnels. Previously, she may have driven to work alone every morning without the slightest problem; now she trembles at the idea of taking the car a block away. Irrational fears seize her if she is alone in a shop or

in a crowded place. The slightest change in the weather gives her chilling fears of thunder, lightning, floods and cyclones. Any experience, at the limit, will have the effect - in the words of one of my patients - of 'scaring me to death if I am alone'.

I the case of a busy housewife who took perfect care of a large family. She was certainly up to the task. When she became depressed, she kept phoning her husband to calm her fears. Or she would ask her mother to stay with her to keep her company. She was afraid to go into the kitchen alone to prepare a meal. Going shopping had become a matter of state. In short, if this woman, or someone like her, is a member of your family, you will recognise the depressive state in her and realise that she is so afraid of being alone that she can no longer do the tasks that have always been a matter of course for her.

What to do when the person is afraid of being alone

This type of fear expresses the fact that the individual is in a state of panic.

Here, too, encouragement will be of little use. It is therefore necessary to ensure that there is always another person with the patient. It is better to have a neighbour or friend who is able to the patient patiently and lovingly in moments of crisis, when fear takes over; who knows how to keep the patient company in carrying out tasks that are not too demanding, distracting him with stories about the neighbourhood, and reassuring him with kind and relaxing manners.

Research by Dr Horsley Gantt of John Hopkins University has shown that a dog that has been conditioned to a state of fear and tension and placed in a situation that causes anxiety will exhibit high blood pressure and an increased heart rate. Blood pressure and heart rate return to normal, as a result of what Dr Gantt calls

the 'person effect'.

This also applies to human beings. When there are fears, nothing can replace the effect of the person on the person. The mediation of the telephone is not enough, nor are words of encouragement in the morning when the person has to be alone anyway. The physical, living presence of the other is the only relief for this condition, until the person obsessed with fears has managed to regain full control of himself.

Fear of death

This kind of fear usually stems from the depressed person's morbid ideas about himself, and the feeling that he is alone with his suffering. He is afraid that if others abandon him he will 'act out' his death impulse and kill himself. The conflict, however, is right here; he does not really want to die, he wants to be free from his chilling premonitions of death, but at the same time he feels he has to play with death because it appears to him as the only relief from such premonitions.

In addition, in the confused state induced by his thoughts of death, he may become obsessed with fantasies about the murders, violence and disasters he hears about. This increases his fear of dying, but at the same time it is accompanied by the fear of causing the death of someone else. As these obsessions worsen, he becomes more and more certain that he will inevitably hurt or kill someone close to him. Ten or twenty times a day he will ask himself, 'Why am I always afraid? What is wrong with me? I will do something terrible, and they will arrest me. How will I ever get better? When will this torment stop? Am I going mad?"

These kinds of fears may seem ridiculous to you. What could be the real basis

for it? Your family member is fit as a fiddle. Why should he or she be afraid of dying? And how could such a calm and gentle person hurt someone else?

What to do when the person has fears about death

These fears have a paradoxical character, as you may have concluded from reading the previous paragraph. If, however, all you can think about is to discuss their sensibility with the person in question, you can save your breath. Fears of death are never meaningless to the person who is the victim of them. Their torment is real. And on top of that, if you dismiss the subject without recognising its relevance, you cause the person's thoughts to turn in on themselves, until they begin to wonder about the terrible thing you are trying to hide from them.

What you need to do instead is to offer the pure truth. Explain to him that depression is an illness, and that because of this the functioning of his nervous system is currently defective. Most people are able to accept the fact that their nerves are in a bad state. So call fear by its name - an obsession. Emphasise that a state of depression characterised by sadness and despondency can induce in anyone obsessive thoughts about death. Remind him that when there was no depression, there were no thoughts of death; explain that such thoughts are part of the symptoms of depression; and assure him that such obsessions will disappear as the depression subsides.

If your family member can accept this point of view, he or she will gradually move away from the dominant thought of death, and begin to objectify it by recognising it as the obsession you have described to them - a symptom that is possible to accept for certain periods, knowing that one day it will disappear just as a cramp or migraine disappears. Some of my patients have gone so far as to become curious about the nature of obsessions, and to start reading texts on the subject to find out more.

There will undoubtedly be relapses, and in such cases you will again have to the depressed person until he recovers; but each time you will see that things will get better. By emphasising the fact that his fears about death are nothing but obsessive ideas you are simply telling him the truth, and the truth in this case provides a diagnostic reality to which the sufferer can cling. This is the best antidote for hysterical fears.

Rising tension 'and loss of hope: a warning sign

These symptoms are usually accompanied by many types of fear, and tension often rises to levels that can be dangerous. They are more evident in agitated depression, but can also appear in slowed-down depression.

The person's appearance and general behaviour reflect the state of tension and despair. The face appears gaunt, the jaw is toneless and there is often excessive sweating. The person is restless, obstinate, hostile, tense and irritable. "I am a lost soul. There is no future for me. Everything is so useless. Why don't you just lock me up and get it over with?" he may say through his tears. What he is telling you is that the depression has become so intolerable that it is approaching the breaking point. His suicidal intent is clear from these words.

What to do about the growing tension and state of despair

In Chapter II I set out the first basic rule to be followed regarding the risk of suicide - always stay close to the person until the danger has ed. In the case of a person in whom the tension has risen so high as to exceed the warning levels, this rule becomes an imperative.

It is extremely unlikely that the potential suicide will take action if there is someone he knows beside him. He will rather wait for the moment when he is alone. (The tendency to self-destruction is something different from the neurotic suicidal gesture, which is usually carried out on the impulse, regardless of the presence or absence of others. See Chapter V).

I the case of a husband who induced his wife to go out to buy milk, and then climbed up onto the roof and jumped off. The wife was only out for a few minutes. In another case, a wife urged her husband to take a break and visit the neighbours, and when he returned he had swallowed a lethal dose of sleeping pills.

I mention these examples because when I say that there should always be someone with the depressed person, I really mean twenty-four hours a day and sixty minutes an hour. If suicidal tendencies are severe and manifest, further precautions must be taken. The patient should not be left alone even while bathing or using the bathroom. He should not be allowed to lock himself in, even if this means temporarily removing the stake. Keep sleeping pills and other potentially dangerous drugs out of his reach; and if you live in a building, beware of the possibility of jumping out of the window.

It is clear that you and every other member of the family have a right to your own moments of sleep and privacy; and such surveillance will consequently involve the cooperation of several family , and perhaps a nurse or helper. The person who harbours fixed ideas of suicide will generally not oppose the one who is trying to stop the act of self-destruction. But the other must always remain with the depressed person: only then can his or her protection be effective.

Needless to say, if suicidal intentions are beyond your control, your family member will have to be hospitalised (see Chapter XVI), because the supervision provided by the family can no longer offer sufficient protection in his present

state.

HOW DO I KNOW IF MY FAMILY MEMBER IS SERIOUS?

There is no foolproof test for determining actual suicidal intent. One must therefore develop a particular sensitivity to the message that the depressed person is trying to convey to the world.

If, for example, he announces (perhaps without any theatrics) that he is going to go to the river, enter the water and 'let himself go', because this 'is the only chance' left to him, do not dismiss his statements as pure nonsense or as an attempt at bluff. Those words, and the tone in which they are uttered, denote the fact that the person believes that he is now 'out' with no remedy, that he has a premeditated plan, and that he intends to carry it out.

If, on the other hand, he complains in a disconsolate tone: "I wish the earth would open up and swallow me. Why doesn't something happen to me so I can get it over with?", at that moment the attitude of the personality is ive and retarded. The person is not planning anything. He is just expressing the desire for something to happen. Suicide, because of his lethargy, is not a looming threat. However, such a person must be watched closely, especially if he improves, because as soon as he gains a little more energy, without this being accompanied by some relief from the psychic pain, he could make the fatal move. This is why it is indispensable to regard most depressed persons as potentially suicidal (whether the self-destruction is the result of increasing tension beyond a certain limit or is provoked by a momentary impulse) until they are well on the way to full recovery.

VIII. SLOWED-DOWN SYMPTOMS. WHAT CAN BE DONE ABOUT IT

Since the slowing down of functions is such an important and manifest symptom of a certain type of depression, it seemed appropriate to devote a special chapter to this symptom. The slowdown manifests itself in the following ways:

1. Expressions of boredom.

2. Complaints about tiredness and weakness.

3. 'Stickiness' of thought, feeling and action.

The person seems overwhelmed by boredom

All of us feel bored at times - the old as well as the young, the teenager as well as the child. In most cases, boredom is a natural phenomenon, whether it lasts a day or two or even a week. A child may return from a camping holiday, for example, where the day was full of exciting programmes, and find at home that he or she "has nothing to do". The child is then in a bad mood, feels despondent and throws tantrums. This kind of boredom can be regarded as a mild depressive state, which generally disappears with the start of school. Even an adult, after having worked for a while on a highly demanding programme, goes through a 'down' phase once the task is completed, in which he cannot see anything new ahead. Again, this is a mild depression which disappears as new interests arise.

One of your family may seem eternally bored, and your conclusion may be that they are 'spoilt', lazy, or lacking in willpower. "Why doesn't he or she do something?" family may ask, impatiently. What they don't realise is that while they see an infinite number of goals that the person in question could pursue, the person himself cannot do so, because the ability to mobilise Fio to action is absent. What is called boredom is in this case nothing more than a delayed depression that no one is able to recognise as such.

The person complains of tiredness and weakness

Your family member may worry that the energy he or she needs to perform his or her tasks seems to have evaporated. If you try to console him by pointing out that he continues to cope with most of his usual tasks, he will reply that this is an enormous effort, and that even the lightest activity, even dressing and undressing, leaves him exhausted, and that the feeling of fatigue never leaves him. If you take the trouble to observe him better, you will find that he is in fact always fatigued, no matter how much rest he tries to get. There may be other complaints, but the main symptom remains constant fatigue.

Slowing down of thought, feelings and activities

When it is the thought that is slowed down, you will find that if you speak quickly, or sometimes even normally, the person cannot catch what you are saying. In order for them to understand, you have to speak with deliberate slowness (as if you were talking to a stranger). He will tell you that his thoughts come slowly to the surface, and that he cannot think fast enough to catch what you are saying.

The slowing down of feelings may take the form of apathy, or the feeling of 'living in nothingness'. The person states that pleasure and pain are meaningless . He has no reaction to you, because of a widespread sense of 'dullness'. And it may surprise you to learn that such apathy - or absence of feelings and sensations - can be as distressing as the most vivid pain, so much so that the person sometimes wishes death would erase it.

The slowing down of activities manifests itself in body movements in general. The person gets up slowly from the chair and shuffles across the room. There is something lethargic in the tone of his speech. Sometimes he cannot even finish a sentence, the speech dies down as if too much energy is required to finish it. This kind of delayed movement (delayed motor activity) is a telltale sign of depression. Internal functions also decelerate. The person digests with difficulty, and complains of stomach acidity, 'air' and constipation.

When such a slowdown exceeds a certain level, it leads to catatonia (reduced muscle tone). Even chewing becomes too much of an effort for the person, so that food remains in the mouth without being swallowed. He may sit in an armchair all day looking straight ahead and without changing position for a whole day, letting his bladder fill up to such an extent that it causes intense pain; but by this time the slackness may have reached such a point that the person cannot even complain about it.

If further deterioration occurs, the patient becomes totally catatonic. Catatonia is the last stage of consciousness in the behaviour of the retarded depressive. The catatonic seems to be reduced to a state of complete stupefaction. If you put him in a certain position, he remains motionless until you put him in. another one. He will no longer swallow even the saliva, which will drip from the corners of his mouth. His gaze is one of total fixity. He will no longer eat, nor will he empty his bladder and intestines. If you try to speak to him you will receive no answer, and he will not even give any sign of having heard you. There is still consciousness, but it is so depressed that it can no longer be stimulated by anything.

How to help the slow person

Whether the person manifests a state of chronic boredom, or constant fatigue, or slowing down of thoughts, feelings and behaviour, use this strategy first:

Try to stimulate and mobilise the patient.

For any kind of slowdown, this kind of approach is indispensable. The person has to be directed away from the disease and back to a life of purpose. You may respond that you have tried, but it did not work.

In this case you have probably used the wrong methods, and a different approach is needed, which could be as follows.

Investigate for a spark of interest

It may be just the flash of a moment in the eyes of your family member: but that is enough. Follow it as a detective would follow a clue. In this case you are the detective in the situation.

You may have thought that your family member is tired because of the boredom induced by the depressive state, and you are not off the mark. These are parallel symptoms. Boredom tends to remain unexpressed. Tiredness and weakness are manifested verbally. But for practical purposes you have to consider these symptoms together. In short, you have to find a way to 'recharge' the depressed

person.

Do not start by asking her what she would like to do. The answer would be "nothing". If you ask her if she would like to go to the cinema, or to the match, or to a club, etc., etc., you will surely get all negative answers. Then take a more circuitous route.

Strike up a conversation on topics of general interest. At first it may be a monologue on your part, but don't stop. Bring up the news of the day or familiar topics. Talk about what you have been doing during the day, what you have been reading lately, or about your plans. Touch on a whole range of subjects, such as the current education system, the political situation, new fashions, inflation, travel, science, the stock market, and so on. Sooner or later you will touch something that will arouse his interest. Pay close attention to this reaction, however small it may be. Do not insist at this point. Be casual. But give her the opportunity to respond. When she does, nod in agreement so that she is encouraged to go on. Sooner or later you will see her diffuse past enthusiasms or perhaps minute irritations. Whatever it is, you will have got what you wanted, because the person will be talking and renewing their interest in something. You have found the right button to counteract their chronic state of inertia, and to pull them out of the sluggish situation they are in.

Another way to provoke the spark of interest can be to introduce inaccurate details into certain subjects of conversation. As absurd as this may sound, it is a trick that works. Look for a topic on which your family member is more knowledgeable than you are; and don't be caught off guard if he or she suddenly bursts out with 'You don't know what you're talking about', and goes on to explain what you are doing wrong. At this point you can comment 'Really? You know I didn't know that at all?" and proceed to ask for further explanation. The part of the person's psychic functions that has remained normal will force him or her to take the initiative, gathering information from the storehouse of memory; and in this way he or she will have taken the bait that you have thrown. This extends their attention span, which is restricted by the disease. You have

achieved the effect of stimulating it. Extending this interest to other fields will then not be too difficult. At this point you can try to mobilise the person, with an activity of any kind.

For example, I once treated a 50-year-old truck driver suffering from chronic depression of the retarded type. He no longer had any interest in work or family, and would sit for hours looking out of the window. He complained of constant fatigue and that life could no longer offer him anything. His family's repeated attempts to get him out of the house were to no avail; all he wanted was to get home as quickly as possible and get back into his armchair.

One day I was talking to him in a seemingly casual way about holiday plans. At one point his memory seemed to be stimulated, and he began to tell me about a house he owned on the lake, where the family spent their summer holidays. A stone wall that lined the driveway was in need of repair. Mulling over the subject, he wondered aloud if it would ever be repaired. We discussed the subject of masonry work, and at the end of the session, with a slight astonishment in his tone of voice, he said to me: "You know, doctor? This time I really enjoyed talking to you like this.

Spring had just begun, and it was still cold, but I persuaded his brother-in-law to take him with him to the lake house the following Sunday. After observing the condition of the wall, they removed the loose stones together and then began the repair work. On his return home, my patient decided that he would go back up there the next day, and he did the same the following day. One morning he telephoned me - he could not come to me that morning. Repairing the wall had become a full-time occupation. In the meantime, he had noticed that the pier, the water pump house and the tool shed were also in need of repair, and he decided to devote himself to these as well. It was not long before the depression was lifted and he was able to return to his regular job.

There are potential motivations of this kind in everyone, and it is these that must

be identified and used to stimulate the person to return to normal life activities.

Organise a precise programme for the day

The slowing down of activities becomes particularly evident in reactive depression (grief) due to loss. When dealing with this type of reaction, empathy will initially predominate over feelings of sadness. But after some time, your main task will be to prevent the person from sinking into their own grief.

I am reminded of the case of a young mother who continued to mourn the death of her five-year-old daughter, the third of three children, who died in a car accident. The father's grief was no less, but was soon overwhelmed by the need to return to work to earn a living for himself and his family. Relatives, friends and neighbours showered her with attention, too much attention. They looked after the children, ran the house, did the shopping, cooking and cleaning for her. And when she went to sleep, there was always someone with her. In this way she was completely immobilized by pain.

The good intentions of others were of no benefit to her, because excessive solicitude can do more harm than good, leaving the field open to pain and weakening the person's resources.

It is clear that a certain amount of time must be allowed for this, but once this period of mourning has ed, the depressed person should not be allowed to abdicate his duties indefinitely. One must see to it that he returns to his duties. If this sounds harsh and inhuman, please believe that this is the only way to save the person from despair.

In the case I have mentioned, one of the family , namely her sister, followed my suggestion. Instead of allowing the woman to languish in bed all day, she forced her to get up one morning. She then organised the whole routine of her household duties for her, jotted down a complete schedule and hung it on a kitchen wall. The schedule included all the tasks her sister would have to perform: when to feed the children, when to clean, when to do the shopping, the laundry, the dinner, when to iron, and even when to read and watch TV. For the first few weeks he was there to help her; by the time he left, the patient was able to carry on alone. By the time he left, the patient was able to carry on on her own. So it was this kind of programming (based on the same principles that govern hospital life) that made her return to her duties and her previous work habits. Eventually, when her natural aptitude for a full and orderly life reappeared, she was free from depression.

Did he still miss the missing child? No doubt. But as time went by, the wound healed and his reactions to the other family returned to their usual ones.

In reactive depression characterised by slowing down, it is essential to use this method of 'routinising' the patient's daily life. If you can organise an effective programme, the doctor and/or nature will do the rest.

Induce the person to activity with encouragement

The patient in this case could be your mother, who is suffering from endogenous depression and is slowed down in every field of activity. Unlike what can be done for the person in a reactive depressive state, it is not possible to organise her life in such a way as to gradually bring her out of her state. People suffering from endogenous depression do not respond to this kind of approach. They would feel cornered and would react with an attitude of defiance. Nor would a careless or authoritarian attitude do any good.

Suppose, for example, you were to ask your mother: "Would you like to go to the cinema with me?". She would probably reply with silence or 'I don't know'. She is too overwhelmed by her illness to know what she wants. Feeling unable to deal with her, you may be tempted to give up and leave without saying anything more. If, on the other hand, you announce without fail that you are going to take her to the cinema with you, because you are tired of listening to her complain about her troubles, there is no doubt that she will flatly refuse, secretly thinking that you are a selfish and authoritarian son, without the slightest understanding for her state. What you have to do instead is to "lure" the patient to the activity, using the weapon of encouragement to move her.

Try to do this. Explain to her that you understand how much she may have suffered (talking in the past tense suggests that depression is now behind her); but that in your opinion, after all she has been through, she is entitled to enjoy life a little. Perhaps the field of possible amusements has narrowed compared to the past, but why not seize the opportunities that may still present themselves? You would like to share them with her.

Your words will not arouse her opposition, because in spite of appearances she is tired of always staying within the same four walls, and your suggestion has a good chance of being accepted. You do not expect the miracle of an immediate response. But now she has something to think about, and she will not fail to reason on the subject.

On the following day, act more directly. Making sure that he can hear you, call the cinema: 'What time is the penultimate show? At eight o'clock? Thank you very much. Throw her a glance and add: "Then we'll make it. At this point you have set a time and given her a deadline to deal with. Now the situation is fluid and delicate. Act with caution. Do not be oppressive. Your mother knows what you have in mind and would like to act in accordance with your intentions. But one false move is enough to ruin everything. If she doesn't protest too strongly, you are on the right track. Wait until it is time to leave, and hand her your coat.

Don't be surprised if she then puts a little lipstick on her lips and brushes her hair (don't rush her), showing an unusual propensity for hairstyling. For the first time in six months you have managed to bring her out of her shell.

Once this first success has been achieved, you have many alternatives. The next time, you could ask her to help you choose a new dress: she knows how much you trust her good taste. Even if this is not true, she will not argue with you; she needs to believe you, because this gives her the feeling again that she is serving something, that she is useful to someone. From now on continue with the encouragement at every opportunity - and watch her become a normal person again.

Unfortunately, family often fail to deal properly with the person suffering from slow depression, assuming a position of authority or defiance, or even of noble forbearance. In none of these cases will any result be achieved.

The same method can be applied in case the depressed person is a father, an aunt, an uncle, a brother, and so on. Use your imagination. A person may respond positively if you ask them to help you take care of the shop or the office, as you can type well (whether this is true or not is of no importance). In another case, she may respond positively if you ask her to take care of the parish charity fair. One of my patients began her return to a normal life when she was found a job at the 'lost children's office' in a city park. Or you could convince the person to help you set up your new high-fidelity system. One of my patients was persuaded to edit some home-made films. Once he recovered he became a ionate amateur filmmaker, until he even embarked on a new career - making documentary films.

By accepting your encouragement the person is stimulated to appreciate his or her potential again. But don't be disappointed if at first he remains in an essentially ive position; it is enough for you to get him moving. In time, as the symptoms disappear, he will acquire new energy, and when healing is

complete he will be ready to take up new activities himself.

The person suffering from endogenous depression almost always responds positively to encouragement, especially if this is combined with gentleness and the hidden power of suggestion.

None of the methods described to help the slowed person can be applied to catatonia. I can only reaffirm that the person who has reached this extreme condition must be hospitalised.

IX. DELUSIONAL SYMPTOMS AND WHAT TO DO ABOUT THEM

Often the depressive state is accompanied by very peculiar and bizarre ideas, which have nothing to do with the person's previous way of thinking. In this case we speak of delusions.

What are delusional ideas?

To give a definition, a delusional thought is a belief that is false and immovable by the means of rational persuasion. In fact, we speak of a 'fixed idea'; and I say 'false' because it does not conform to reality.

The delusional ideas of the depressed can be very puzzling. A woman who had brought her husband to me for an examination summed up her bewilderment in this way: "Doctor, he says things that simply aren't true; and what's more, he manages to distort everything I say. I think he is out of his mind.

But even when the other of the family become aware of the delusional character of the depressed person's speech, they often withdraw and try to avoid the problem because they feel unable to cope with it. However, there can be no more obvious sign of the disturbed psychic state of the person than the occurrence of this kind of delusion. They indicate a very dangerous situation for the patient and those around him, and medical intervention is imperative. Only treatment specifically aimed at restoring normal brain processes can erase the delusional ideas.

At the same time, however, the cooperation of the family is necessary. Before discussing the various types of delirium that can be encountered in depressive states, I would like to set out two general rules that must be followed in the presence of any delusional state.

First rule: do not try to reason with the person who is delirious.

I have known husbands and wives who spent hours and hours trying to convince their spouses of the absolute lack of any real basis for their claims. However sincere these efforts may be, it is a waste of time and energy.

The person who manifests delusional ideas is a person whose mental processes are impeded by chemical imbalances in brain function that prevent a normal flow of energy to the nerve circuits. The behaviour of such a person is based on a distorted perception of reality; and as long as the chemical imbalances persist, so will the delusional ideas persist. Attempting to modify them with the weapons of reasoning will only over-stimulate the brain processes of the depressed person, triggering and extending the delusional process, since the deranged rational apparatus is unable to withstand the impact of the arguments of others. The crux of the problem is this: when you try to reason with him, you are only attacking his delusional model of orientation, which frightens him. You consequently become an enemy to be overpowered at all costs. So by trying to reason with him you are fighting a losing battle.

Second rule: prevent the person from 'acting out' his delirium

You must never let the person 'act out' their ideas, devoid as they are of any real foundation.

If the person is allowed to act in accordance with his perverse ideas, this can result in often very strange behaviour. If the person merely mulls over his ideas, or expresses them only verbally, he will not encounter serious problems. But if on the basis of these ideas he takes action, anything can really happen. That is why the family must always be on the alert, anticipating any move to action, and must take full responsibility for this, using force if necessary.

Paranoid delusions

The word paranoia means 'distorted thinking'. In most cases the distortion of mental processes becomes apparent when the person thinks that someone or something is trying to harm them. Your family member may start to become suspicious of everything and everyone. You know that neither you nor anyone else has bad intentions towards them, but you cannot make them understand this.

A typical paranoid delusion might be a statement like this: 'The astronauts are sending out secret magnetic waves to destroy me', or 'The radio announcer is spreading coded messages telling everyone dirty lies about me'. Another example of a paranoid delusion is when a man or woman accuses his or her spouse of infidelity, when the accusation is completely unfounded. I have seen cases of people in their seventies, and even eighties, accusing their husband or wife (of the same age) of 'having it on day and night under their eyes' with their (30-year-old) neighbour. In another case, a delusional chemistry student may accuse his professor of tampering with his laboratory equipment in order to fail his examination; a lorry driver may be convinced that every other driver is trying to run him off the road; a secretary may accuse her boss of tapping her home phone in order to find out about her intimate affairs.

Delusions of theft are also common, and the sufferer may refuse to leave the house, because only then can he 'catch the thieves red-handed'.

People suffering from paranoid delusions distort the facts in order to justify their position. A woman who suffered from hot flashes and menopausal depression complained of excessive heat in her flat. At one point she accused her husband and the building's doorman of deliberately keeping the heating too high in order to aggravate her condition and "kill" her. Her husband turned off all the radiators in the house, but she pointed at the pipes, which of course remained hot. When she was told that there was nothing to be done about them, she shook her head and said: "Oh, no. I was quite right. I was quite right. I knew you would find some way to make it hot and make me sick.

Another paranoid manifestation may be the patient's refusal to take the prescribed medicines, because he 'knows' that they are actually poisons, and that the person istering them wants to kill him. For the same reason he may go so far as to refuse food. A severely depressed patient of mine declined all invitations to dine at other people's houses, because she was sure that even at her daughter's house people were trying to kill her.

What to do when the patient manifests paranoid ideas

In cases of paranoia, it is especially important to avoid taking action, because the results can be disastrous. When the paranoid person starts writing obscene or accusatory or threatening letters to strangers or public figures, try to intercept them before they are sent. Then there may be a case of a man whose delusions lead him to believe that his wife is planning to eliminate him. If he is not kept under control, he may go so far as to hit her that he injures or kills her. Or a young woman may imagine that every man she meets on the street is making a sexual approach to her, and may eventually accuse an innocent bus enger of attacking her and demand his arrest. In any such case, one must act in advance to avoid the embarrassment, publicity and legal complications that may follow. And the best way to avoid such consequences is to seek medical attention immediately, as soon as delirium manifests itself as a symptom of a disturbed emotional state.

The paranoid individual who no longer trusts anyone is usually a person who has felt robbed of his affections in life; it may also be the opposite case of a person who has never learned to give others anything of himself. In any case, however, you are not usually faced with the most loving person in the world; but it is also remarkable how an irritable, agitated depressive with paranoid manifestations can react to demonstrations of kindness and affection. If, for example, your sick family member is just such a person, and if you take the trouble to let them know how much you love them, and how much you want them to get well so that you can see them free of the suffering of depression, you will see them literally melt away, wanting to be able to reciprocate your affection in some way.

So try to keep an eye on him, looking for every opportunity to show him your love, and thus reduce the distance between him and the world. When you find that with this attitude you can actually reduce the anger and distrust that depletes his energy, and take him step by step towards healing, I am sure you will agree with me when I assure you that your warmth and affection will not be wasted.

Delusional ideas of guilt and unworthiness

I have already said that feelings of guilt are a typical symptom of many species of depression; in one way or another the person is telling you that punishment for their misdeeds is inevitable. In the case of delusional manifestations, however, the feelings of guilt and unworthiness have no real basis. They are fixed and distorted ideas, and their content is false and inappropriate.

I am reminded of the case of a 62-year-old woman, whose life was absolutely exemplary, who fell victim to a severe state of depression and was seized by intense feelings of guilt: she was convinced that she had been guilty, at the age of 12, of stealing rosary beads from her aunt (in reality, the real culprit had been her cousin, but following her illness she now identified herself with the thief). A young lady, every time she went through an episode of depression, accused

herself of very serious infidelities (totally fantastic), thus manifesting a characteristic delirium sometimes related to guilt feelings for childish masturbations. Another patient "confessed" to me that for years he had been falsifying ing records, thus cheating his business partner. The latter, however, testified that the s had always been extremely accurate, and that my patient had always taken care to record every movement of their t funds down to the last penny. Nevertheless, my patient was always talking about the terrible fraud he had committed against the other; in his own eyes he had committed a criminal offence, and therefore no longer deserved to live.

THE MOST MIRRORED PEOPLE ARE THE ONES WHO FEEL THE MOST GUILTY. It may seem strange to you that the person who feels most guilty in a state of depression is the one who has always been of exemplary morality in life. You have already met this type of person in Chapter V, whose blamelessness is such that he puts others in awe, and whose strictness and firmness of morals are well known. If your family member has always been such a person, when he suddenly starts proclaiming his absolute guilt, you cannot fail to be astonished.

Let me clarify the situation. In such cases, depression undermined the inflexibility of the person's value judgements. These judgements have functioned as psychological defences. The illness has now shaken them, and the person complains about his condition. "Why did something like this have to happen to me?" he cries, unable to forgive himself for such a loss of emotional control. In addition, the imbalances in brain chemism that I mentioned at the beginning of the chapter induce significant aberrations in his thinking. Consequently, what the delirium leads him to conclude is that since depression gives him such unpleasant sensations, he must surely have done something wrong to deserve this. Sooner or later he comes to fancy some stain on his moral rectitude which may in some way explain the illness, and the delirium explodes in a full declaration of guilt.

NEED FOR PUNISHMENT: There is then the very real danger of the person's need to punish himself for the evil he has done, so that he can finally atone for

his sins. Psychic suffering does not seem to them to be a sufficient punishment. Perhaps only death will suffice. At this thought she cries and becomes despondent. I transcribe from a recording made during a session with one of my patients: "I am worthless. I am not worthy of your respect, doctor. I deserve neither your kindness nor your consideration. Now I must have made you sick, and I have spoiled everything. You should leave me alone and not worry about what might happen. You must make me pay for what I have done, and that is all you have to do.

Since friends and family are not willing to punish him as he wishes, the depressed person may seek in suicide a way of redemption from the feelings of guilt and the resulting tension. A patient of mine who had once tried to commit suicide asked me to give him an injection of "strong stuff - but a lot of it..." to kill him. Haunted by his delusions of guilt he accepted the treatment, but with the hope that a fatal outcome would follow, since he no longer felt worthy of being in the world. After his recovery he had completely forgotten all about it, and when he was told about the episode he could hardly believe it.

What to do when there are delusional ideas of guilt and unworthiness

Delusions of guilt can only be calmed by taking a firm and authoritative stance; this means that you must tell your family member that you forgive him for everything, and consequently forbid him to feel guilty again. Absolute categoricalness is necessary in this respect, since the primary aim here is to relieve the patient of his feelings of guilt and the agitation that results from it.

Such an approach is particularly effective when the person feels that he has failed to meet your expectations, and that this fact fills him with shame. There must be no hesitation in your words and tone, as the depressed person will immediately sense it and doubt your ability to absolve him. It may therefore be necessary to your claims of forgiveness by explaining that you have decided to take the blame on yourself, and that you want to take responsibility

for it instead. This also works if he feels that he has disappointed or harmed someone else, or even just himself. Since you are dealing with a guilt that relates to events that never happened, you are free to use any device that may serve to calm him down. The person is more than willing to accept your authority and your power to forgive him his faults; what he wants above all else are the magic words of absolution. Be resolute in pronouncing them, and observe the relief that results. Even if the patient's response is only an incredulous smile, you will have made a first dent in his depressed condition.

Delusions of unworthiness, unlike in the case of loss of self-esteem (Chapter VII), cannot be solved by reasoning either.

When the person loses self-esteem, he can always understand what the true reality is, can see things in perspective, and can change his point of view. However depressed he may be, he is fully able to orient himself, and responds to the promptings of reasoning and logical thought.

Delusions of unworthiness, on the other hand, are rooted in unreal events and are made fixed by the distortion of the faculties of orientation and judgement. They must be dealt with, however, in order to alleviate the suffering, upset and despair that accompany them.

A young university professor, for example, who had been awarded full marks and was held in high esteem by students and colleagues, fell into a state of depression characterised by delusions. "My life is a complete fiasco," he complained. "I am worthless... I would like to die." He felt unworthy of his position, and it was clear to him that he should never have been trusted so much; certainly he had been given the job because his father was an influential man. The latter was a taxi driver who had worked hard to ensure his son's education, had no with the academic world, and was completely baffled by these statements of my patient.

In dealing with such delusions your most effective weapon - apart from psychiatric treatment - is the strengthening of his sense of reality. You must always put the substance of the facts, and only the facts, in the foreground, and the patient must always be led back to these. The young professor was continually and firmly reminded of all the work he had done to reach that point in his university career and the position he had earned by doing so, and at the same time he was assured that whatever he got he had earned honestly. He was compared with the scholarships he had won, the jobs he had obtained, his brilliant dissertation, the offers he had received from other universities, the book he had published and which had been so well received by the critics. In other words, he was kept "busy" with this kind of information. No attempt was made to convince him by reasoning the falsity of his delusional story about his father's influence on his career. Every time he returned to it, a diversion was created to make him forget it for the time being.

One day, after a few weeks of treatment, he was suddenly very surprised to realise that the person whose many merits were being discussed was in fact himself. Not much time ed, and he was once again able to return to the real world at full speed.

Accepting the delusional ideas of unworthiness of the depressed person, just because it may be easy to nod and agree, can have very destructive effects. Such an attitude reinforces the patient's abnormal ideas and pushes him further away from reality. Note well, however, this difference: you do not have to agree, but neither do you have to discuss the delusional ideas (this is, as you , the first rule), or try to prove their logical inconsistency (as I have recommended in the case of loss of self-esteem). What you have to do instead is to focus the patient's attention on objective and indisputable facts. so that you can put the delusional ideas aside and replace them with real content. As the patient responds positively to psychiatric treatment, your programme of readjustment to reality will also begin to take effect, modifying his way of thinking, until the delusional ideas that oppress him are completely eliminated.

Delusional ideas of poverty and nihilism

Delusional ideas of this kind are in fact the ultimate consequence of the sense of unworthiness. The depressed person will convince himself that he no longer possesses anything, or that he is no longer anything. He will feel obliterated, by poverty or non-existence.

In delusions of poverty the person convinces himself that he is ruined and reduced to misery. He will claim that he no longer owns anything, and that he considers himself lucky to still have the clothes on his back. The contradictory nature of his statements becomes particularly glaring if you know that your family member has no real financial problems. Any document you put in front of him will claim that the house he lives in is not his, and must surely belong to someone else. If you show him bank books or securities in his name he will be shocked, but will insist that they do not belong to him. He may even refuse to collect his pension, saying that he is not entitled to it and that someone must surely have made a mistake.

The nihilistic delirium is an extension of the poverty delirium. The patient's denial of his own existence and that of the world may be partial or total. He claims that 'everything is dead, gone. Everything is useless and dried up. The world is empty'. He describes himself as a corpse, without heart, stomach, or any other internal organ. Of course, he sees you and speaks to you, but he is sure that neither you nor he are actually 'there', just as everything around you is not there either. In his eyes everything is shadows and vapours, absolute nothingness.

Delusions of this kind do not usually involve great psychic suffering, and the patient rarely has suicidal intentions. But such a conviction of the complete nullity of the world and of oneself can induce in the patient a state of very serious regression.

What to do in the face of delusional ideas of poverty and nihilism

Delusional ideas of poverty may lead the person to give away everything he or she owns, since he or she is convinced that he or she is not the rightful owner to begin with. Do not make the mistake of underestimating the patient's determination and cleverness in devising ways to achieve his end. It is not difficult for him to convince a lawyer or an (who are unlikely to understand that the person is in full possession of his mental faculties) to draw up liberating documents to this effect, so that all his property can be devolved to others.

It is up to you to stop such transactions by ing the lawyer or the other parties involved, clarifying the of the matter and stopping the sad farce. In extreme cases, it may be necessary to go to court to have your family member disqualified in order to preserve their assets. (See chapter XVIII).

A patient of mine suffering from nihilistic delusions was firmly convinced that she had no head, and it was impossible to convince her of the contrary. Even if she was induced to touch it or in some way to feel it, she continued to insist: "No, it's not there any more, really, it's gone. I just feel an emptiness". And consequently, from her point of view, since such an important part of her body was missing, she had no reason to take care of herself in any sense.

In such cases, self-neglect reaches extreme peaks; one of the family has to take care of the person, and look after and wash him as one would a small child. One of the family has to take care of the person, and care for him, and wash him as one would a small child. To discuss the sensibility of her beliefs would be to no avail; and to tease her would be simply cruel. In most cases the best thing will be to ignore her claims about it; nihilistic delusions cannot be removed from you, because only psychiatric treatment can do that. But

the protection and care you will be able to provide will preserve the person's health during the depressive episode, so that when mental stability returns he will be in good physical condition and able to look after himself immediately.

Delusions of grandeur

These delusions are a symptom of the 'up', or manic, phase of manic-depressive disorders and other endogenous depressions. As I told you in Chapter III, they are manifestations that in manic-depressive illness can alternate with phases of depression. Delusions of grandeur may also indicate a delusional phase characteristic of the depressive condition with toxic aetiology.

Such episodes of intoxication may come on suddenly, or slowly evolve from the depressive picture; the person appears convinced of his omnipotence, and his state of exaltation may lead him to declare himself king, dictator, statesman or God.

What to do when delusions of grandeur occur

There is absolutely no way of appealing to the common sense and judgement of the person suffering from delusions of grandeur. What can be done is to prevent him from taking action on the basis of this kind of exalted feeling. Sometimes the maniac will engage in crazy speculative ventures, issue invitations to huge parties, sign contracts for the construction of housing estates, or negotiate the purchase of a fleet of taxis. In such cases it must be stopped. It is clear that one cannot afford to play with such a condition, which invariably requires recourse to the psychiatric institution; and the more immediate this is, the better it will be for the patient's health and general well-being.

Religious delusions

This type of delusion occurs in men and (especially) women who have led lives characterised mostly by loneliness and abandonment, and who turn to religion as a panacea in the absence of a satisfactory sense of identification and fulfilment on a social and sexual level.

The delusional depressive may then engage in extravagant penitential rituals. The religious delirium is coloured by various bizarre forms of devotion, up to cases of 'miracles' in which the person witnesses the appearance of saints and Madonnas. Such religious fantasies may have no connection with the person's previous beliefs. The illness causes the depressed person to mix facts and products of imagination, quoting (out of order) long ages of Scripture to prove his guilt; and sometimes he will give himself to prophecies about the coming of the Lord, now made inevitable by the sins and iniquities of the world.

Religious delusions are also manifested by young men and women suffering from depressive states in conjunction with various types of psychosis. In the elderly, strange or exaggerated religious ideas can usually be ascribed to senility.

What to do when the person manifests delusions of a religious nature

When the victim of delusions characterised by religious mania pursues his devotional activities, it becomes necessary to follow his movements closely. He may spend hours kneeling in some dark corner of a church, forgetting to eat or to attend to any other need of his body. If the situation is not taken care of, the sick person loses weight, and becomes undernourished and an easy prey to organic disease. In other cases, by approaching strangers in the belief that he is the bearer of the 'word of the Lord', he may fall victim to acts of violence. Such occurrences can be avoided if one ensures that the person in question never

leaves the house alone.

In addition to such precautions regarding personal safety, you must show love and understanding to an extent that will compensate for the years of loneliness and isolation. This will not change the delusional ideas, but it will give the person comfort and inner peace that will diminish his need to indulge in fantasies of bliss. For the rest, continued care and sympathetic attention in a calm and affectionate environment will probably be sufficient to eliminate the fanatical preoccupation with religion and to reorient the patient to reality.

Somatic delusions

The term somatic comes from the Greek word soma, meaning 'body'. In depressive states, it is usually the weak person, incapable of independence, who is prone to these kinds of delusions. The patient fixates on some organ or body part, claiming that it is sick (when in fact there is no abnormality), or saying for example that an arm is 'drying up' when it is perfectly intact. In other cases the person may think that their nose is shrinking, or that their stomach is shrinking, or that the normal ridges in their gums are actually a symptom of cancer of the jaw.

None of these delusional beliefs has the slightest basis in real disturbances, except by coincidence.

What to do in case of somatic delusions

One of my depressed patients was convinced that she had a large mass of faeces in her rectum. She had been frantically trying to get rid of it, going so far as to

give herself up to forty enemas in a day, with the consequent danger of serious physical damage. The completely negative results of a whole series of tests were completely ignored, and there was no point in reminding her that perhaps the depression had caused changes in her thinking. The abuse she was making of her body in this way could not be stopped until the family took matters into their own hands by getting rid of the enteroclyte equipment and making sure the patient did not replace it with another.

Somatic delusions can grow to incredible proportions. I have treated more than one patient who has had countless X-ray and laboratory examinations done. Sometimes the question can even be: WAS THAT OPERATION REALLY NECESSARY?

I a woman who had her jaw operated on six times, because she had managed to convince six different surgeons that she had an 'inflamed cyst' that was causing her excruciating pain. Others manage to convince the surgeon that the removal of a certain body tissue will finally eliminate a persistent pain that "keeps them in a state of constant nervousness and exhaustion" (depression).

The person who manifests somatic delusions is often very convincing in the exposition of his symptoms. If, however, she finally manages to be operated on, the delirium shifts to other objects, such as certain "adhesions" (residue of the operation) which make her feel "all pulled in".

The person will never be satisfied with the results of any medical or surgical examination, because the delusional state prevents him from accepting the diagnosis of normality, as well as from realising that the picture of his false symptoms does not stand up. This is why you and the family doctor must block any attempt by the patient by explaining the patient's psychological state to the specialist called in for a consultation. In short, you must make sure that no medical or surgical measures are taken in accordance with the delirium of the depressed person, however much this may be done in good faith.

At the same time, psychiatric treatment must be initiated to remove the primary disorder, i.e. depression.

PART TWO - OVERCOMING DEPRESSION

X. PHARMACOTHERAPY

Medicines are not a recent discovery. Already in antiquity, medicines were istered for illnesses that included symptoms of depression, anxiety and excessive tension.

Over two thousand years ago, Hippocrates prescribed hellebore for emotional disorders. Before that, Chinese doctors treated nervous disorders with ephedrine. Medical literature tells us that opiates and other plant extracts were widely used in many ancient cultures for their sedative effect. And it is interesting to note that the medicine men of primitive cultures used extracts of cocoa leaves, peyote roots and poppy seeds to counteract the suffering or lethargic state of depressive and anxious states.

Nowadays, drugs are used that are mostly synthetic chemicals, although plant extracts and other products continue to be used. The pharmaceutical arsenal currently used in the treatment of depression, however, consists mainly of synthetic compounds and chemicals developed over the last thirty years, most of which were introduced from 1955 onwards.

Here I would like to familiarise you with the most important types of medication generally used for depression.

Tranquillants (sedatives)

Sedate means to calm or slow down some function of the body. The doctor may

prescribe a certain medicine, telling you that it is a gastric or intestinal sedative: he means in this case that he expects the medicine to reduce acid secretions in the stomach, or eliminate painful contractions of the intestines.

Similarly, sedatives are istered to reduce excessive activity of the nervous system or to alleviate a widespread sense of stiffness or tension in the body, i.e. to relax or calm the person.

Tranquillizers, used as sedatives, are part of the latest generation of synthetic drugs. They are often used for the specific purpose of reducing fear, anxiety and irritability resulting from depression, and are given to reinforce general antidepressant drug treatment.

Sleeping pills

The most common of these are barbiturates, which have been on the market since the First World War. Previously, drugs commonly used to induce sleep were bromides and opiates. The use of opiates and other narcotics has been appropriately regulated and restricted to medical uses by most governments; in recent years, barbiturates, as well as many other synthetic drugs, have been included among the substances whose use is regulated by laws.

There is often confusion between the term sleeping pill and the term sedative. This is presumably due to the fact that most sleep-inducing drugs (also known as hypnotics) can also be used as sedatives to reduce nervous tension, taken at oneeighth to one-half the dose needed to achieve the hypnotic effect. Conversely, some sedatives (or tranquillisers) can also be used as sleeping pills. If you have ever taken a sedative, you will have noticed that it also induces a slowing-down and drowsy effect.

Stimulant drugs

These substances have the opposite effect to tranquillisers, increasing the level of excitation of nervous system activity. Such drugs are used to promote a state of greater general alertness, facilitate faster reactions, sharpen perceptual faculties, and temporarily alleviate a state of depression or low mood. Most of the stimulants in use today are variants of those natural extracts and synthetic compounds I mentioned at the beginning of this chapter. The most common natural stimulant, known to all, is caffeine. It is found in its natural form in coffee and tea, and as an additive in 'cola'-type drinks (it is responsible for the slightly stimulating effect of these drinks).

Specifically stimulant drugs generally contain one or other variety of amphetamine (amphetamine is a synthetic substance that nevertheless closely resembles (1) ephedrine, originally extracted from plants; (2) mescaline, contained in peyote; (3) adrenaline, a powerful stimulant produced by the body itself as an energising hormone). Other synthetic stimulants, unrelated to caffeine and amphetamine, are entirely the product of chemical and biological research.

Stimulants also serve to reduce the appetite, which is referred to as the anorectic effect. It is precisely for this purpose that they are used in certain cases of obesity. In my opinion, however, many people with an abnormal appetite who apparently take such drugs to control their food intake actually need the stimulant effect to counteract the symptoms of a hidden, albeit mild, depression. When the depression is overcome, the urge to overeat also disappears.

On the other hand, when a depressed patient has lost weight and needs to regain it, this may be a contraindication to the use of stimulant drugs, as the anorexigenic effect will further diminish their interest in food. It is then up to the doctor to dose the medication in such a way as to stimulate the patient without

affecting their appetite.

Stimulants cheer a person up by activating the brain's chemical reserves, thus accelerating the speed of nervous processes. The resulting feeling of increased energy, even if it only lasts a few hours, can be a very effective measure in cases of mild depression and occasional states of fatigue. If, however, the stimulating effect of the drug is used for too long, say every day for a few weeks, the body's reserves may be reduced to a dangerous limit, setting the stage for mental exhaustion and nervous collapse.

Antidepressant drugs

Antidepressants are sometimes referred to as 'psychic energisers' to differentiate them from stimulants. Apparently, their effect is achieved by stabilising the brain's chemical balance, which facilitates the age of nerve impulses through blocked or inhibited brain circuits (slowing down). In other words, they help the nervous system to integrate and transmit its messages throughout the body with greater efficiency and ease.

Antidepressants, however, unlike stimulants, do not artificially activate the nervous system, and therefore do not deplete energy reserves. They are therefore prescribed as specific in many types of depression in order to improve a person's mood and bring him or her to a more stable emotional level.

Although the concept of an antidepressant substance is not new in the field of medicine, most of the 166 compounds and synthetic preparations that can be considered effective and reliable were discovered, as mentioned above, after 1955.

ing drugs

In addition to the four main categories of medicinal substances I have described, which are used specifically in states of depression, other substances are also used to relieve symptoms that vary from case to case. The doctor may, for example, prescribe gastric sedatives and acidity medicines to relieve stomach upset, nausea and burning; or tonics to stimulate the appetite. In other cases, hormonebased drugs are used to stabilise glandular metabolism, or antihypertensives to reduce excessive blood pressure. Then of course there is the old aspirin remedy for headaches and other non-specific pains.

What is the benefit of the drugs?

It can roughly be said that antidepressants (of which there are several types) are the most beneficial drugs. However, the timing and dosage are of crucial importance here. For example, you will need to wait between one and six weeks before you can assess the effect of a given antidepressant with full knowledge of the facts (two weeks on average). In order to achieve the best results, the doctor will usually prescribe a maximum dosage in the first three weeks. He or she will also want to observe your family member closely; firstly, to make sure that there is no risk of suicide attempts; secondly, to record improvements and adjust the dosage if necessary; and thirdly, to make sure that the drugs do not give rise to harmful side effects (see next paragraph). In order to monitor all this, the doctor will want to see the patient at regular intervals in his office, or at least keep in touch with you by telephone.

If there is no significant improvement in the depressive state by the sixth week, it is very likely that the prescribed medicine is not suitable. It will then be replaced by another antidepressant; if one type does not work, there will be another that does.

The tranquillisers, stimulants and sleeping pills that the doctor can introduce into the treatment programme will help to reduce excessive tension, recurring thoughts, obsessions, fears, sensory disturbances, insomnia, and other symptoms that hinder the healing process.

Side effects of the drug

There is no medicine that will induce all and only the desired effects in every specific case. In one case aspirin may solve a headache; but in another it may irritate the stomach and give rise to heartburn, or cause a ringing sensation in the ears. Symptoms of this kind are called side effects.

Antidepressants, tranquillisers and stimulants, all powerful and complex chemicals, can give rise to a wide range of side effects, both in different people and in the same person at different times. Most of these effects are not particularly serious. A certain antidepressant, for example, may in certain cases result in dry mouth, mild constipation and temporary blurred vision. And although such symptoms may be rather boring, they are not cause for concern.

But what if a person's particular sensitivity to a specific medicine causes symptoms to become more severe? What are the dangers? Although to a very small extent, such cases can occur. Some drugs, for example, can increase or decrease blood pressure, particularly when combined with alcohol, certain foods and other medicines. Others can damage white blood cells or red blood cells, opening the door to infections, liver disease or other complications. But if your depressed family member undergoing drug therapy is kept under close medical supervision, there is no danger of major consequences.

Have we said everything?

Certainly not. I have given you some general information on some of the drugs used to treat depression, but this is not the place for detailed information on all the drugs currently available. Firstly, the sheer number of varieties and brands on the market would make this a daunting task. Secondly, each specific medicine in itself represents a specific problem because of the extreme variability of individual reactions, as I mentioned in the previous paragraph. And consequently, although it seemed appropriate to me to enable you to find your way around the field of drugs used for depression and to discuss the subject with your doctor with full knowledge of the facts, the responsibility and authority for prescribing and dosing these drugs rests solely with him.

What is the best medicine?

No one medicine can be regarded as the absolute best, mainly because no medicine actually cures depression. Medication may relieve some of the suffering caused by the illness, or partially remove the most oppressive symptoms. But only the particular medicine or combination of different types of medicine that suits your family member can be called 'the best'. The good outcome of the treatment will be the result of the doctor's experience plus his programme of trial and error in the specific case of the individual patient.

Suppose, for example, that your family member cannot tolerate the effects of a certain antidepressant, which nevertheless has a beneficial effect on the depressive state. The doctor will therefore decrease the dosage of the drug, or replace it with another one. In another case there may be no side effects, but the medicine does not work. This may mean that it is necessary to increase the dose. Or a certain medicine may work very well with another patient, but not so well in the case of your family member. This may mean that it needs to be combined with other drugs in order to achieve an optimal effect. There are so many variables at play that calling a certain medicine 'the best' would be like saying that a certain food is 'the best food'. The answer then is: it depends.

How long should treatment with medication last?

Drugs do not have the same immediate effect on depression as, for example, an antibiotic has on an infectious disease. The effect they have is to and maintain a satisfactory level of nervous functions while the person approaches recovery. If the depression is chronic, pharmacotherapeutic treatment may be continued for a year or more. In most cases, however, treatment with medication lasts three to six months. In certain cases of acute but brief depression (lasting a few weeks) the person returns so quickly to a state of complete normality that the doctor may discontinue the medication altogether (as you will recall from Chapter I. some depressions can resolve spontaneously).

General results of pharmacotherapy treatment

Experience shows that treatment with antidepressant drugs (without the use of other methods) leads to recovery in thirty-five per cent of patients with moderate and acute endogenous depression, and in sixty-five per cent of patients with reactive depression. These percentages are reduced in cases of severe and chronic depression. However, the likelihood of recovery or significant improvement increases considerably if physical and psychotherapeutic methods are used in addition to medication.

XI. YOUR ROLE IN PHARMACOTHERAPY

In contrast to what generally happens in the case of organic illnesses, depression cancels out the patient's ability to manage the care plan by himself, or to arrange things so that the plan can be managed by others. This is a task that requires too much effort, and implies the need to make a number of decisions that the depressed person cannot cope with. Even just picking up the phone, dialling a number and talking to a nurse to make an appointment can be a task far beyond his or her capabilities.

Taking the person to the doctor

It is therefore necessary for someone else to take charge of the situation. That someone could be you.

Once the doctor's office has been called and an appointment made, simply tell your family member, without any unnecessary discussion, that he or she must get ready to go to the doctor and that you will be there to keep him or her company. If he tries to protest, point out to him, without arguing or getting heated, that you are not a doctor, that you are not able to treat the symptoms he complains of, and that it is therefore necessary to consult a specialist. You may add that you are sure that his illness is nothing serious, but that the only way to remove all doubt is to have him examined. Then drop the subject until it is time to leave the house. In most cases the person will not object, and may be secretly relieved that you have taken matters into your own hands.

The care programme

If the doctor diagnoses a depressive state in your family member, you can also expect him or her to assess the intensity of the disorder. If the depression seems only mild and does not interfere too much with the patient's normal duties, the doctor may decide to leave the recovery to time, nature, ive medication and the course of events. In this case he or she will simply prescribe stimulant medication, perhaps a tranquilliser to take from time to time, and if the patient cannot sleep, a sleeping pill.

If, on the other hand, the depression causes more disturbance - i.e. it is approaching a level of moderate intensity - the treatment programme will probably hinge on antidepressant drugs.

Antidepressants: what precautions to take

These drugs must be taken daily and regularly, and are initially istered at a maximum dosage in order to speed up the achievement of initial results.

It is your job to make sure your family member takes them according to the doctor's instructions. Keep an eye on him/her. It will be easy to tell if he or she can be trusted or if you will have to remind him or her to take the medicine at the prescribed time each time.

At the same time, bear in mind what we said (in chapter X) about side effects. In the case of antidepressants these may consist of:

Slight dizziness. In this case it is absolutely not appropriate for the patient to

drive the car. Make sure that he does not do so.

Dry mouth. In some cases this is a symptom that can disturb the patient to a considerable extent. The expedient of having the patient suck on a sweet can be used, which not only alleviates the problem, but also helps to eliminate the 'strange taste' that often accompanies it. For many people, this is a symptom of the same depressive state, even before the start of antidepressant treatment; they are therefore used to this condition and are inclined to accept it.

Perspiration. This can be remedied by frequent bathing and changing of clothes.

Constipation. The occasional istration of small doses of a mild laxative (e.g. milk of magnesia) will in most cases be sufficient to overcome this.

Slight blurring of vision. Your family member may complain of worsening eyesight and insist on a new pair of glasses. However, wait until the end of the treatment and see if the condition persists. It will probably disappear.

When can the first results of antidepressant treatment be expected?

Do not expect immediate results. As I mentioned in Chapter X, on average you will have to wait two weeks before you can the first significant results. That is why you will need to do everything you can to encourage the patient during this time, which can put their nerves to the test. You will not be alone in this task, as the doctor will also take it upon himself to encourage the patient, either by regular visits to his office, by telephone, or both.

Once the first breach in the wall of depression has been made, the doctor prescribes maintenance doses of the same drug (usually varying from one third to one half of the therapeutic dose) for a period of three to twelve months (or more).

Other medicines that can be taken together with antidepressants

Antidepressants are often combined with tranquillisers, sedatives and sleeping pills. However, it can be harmful to take stimulant or anorectic drugs together with an antidepressant. This is why the doctor must always be informed of any medication the patient is taking during treatment. Keep any such information in mind before the first visit, and tell the doctor about it before other details that you or the patient may consider more urgent slip your mind.

However, vitamins may be given, and there are no contraindications if you give your family member one or two pure aspirin tablets for a headache or pain of some kind. You will not be giving them aspirin-based compounds, however, as many of these contain caffeine, which may be incompatible with the antidepressant.

Also bear in mind that alcoholic beverages are incompatible with many types of antidepressants. The combined reaction of the two substances can precipitate sudden changes in blood pressure and result in intense drowsiness or severe headaches.

Precautions to be taken if tranquillisers have been prescribed

You may have heard, with regard to tranquillisers, the strong and mild.

These are imprecise and misleading, since all tranquillisers are powerful chemicals, and the real distinction is in dosage. For a 'mild' effect, the doctor will prescribe a smaller dose, and for a 'strong' effect (such as when the tranquilliser is used to slow down brain function as a hypnotic) he will prescribe larger doses. On this subject, I would like to point out that because tranquillisers, like antidepressants, can cause dizziness and drowsiness, you must ensure that your family member does not get behind the wheel for as long as the effect lasts. This is not only because of the drowsiness effect, but because the drug increases a person's reaction time and dulls their attention, making driving very dangerous.

Most tranquillisers can also be combined with other medicines, but in some cases there are incompatibilities; make sure you are aware of all the medicines your family member is taking, and always consult your doctor.

Another recommendation concerning alcohol: when combined with alcoholic drinks, tranquillisers can have a narcotic effect. Some of my patients who habitually take tranquillisers have learned that they can take the tranquilliser and afford a glass or two (but absolutely not more) in the course of an evening without unpleasant consequences. For others it will be necessary to wait at least four or six hours after the 'pill' before they can touch alcohol. In any case, always remind the patient of his personal tolerances before he goes out for a social evening, and keep an eye on him at all times. Any indulgence in this respect is inissible.

Tranquilisers are not specific drugs for depressive illness. They serve to reduce the anxiety and agitation that often accompany depression. If, however, your family member does not want to take them because he or she is bothered by the dull or 'drugged' feeling that the drug induces in his or her particular case, the best thing is not to insist, leaving him or her to cope with the tension and anxiety on their own until you have obtained something more suitable from the doctor.

In some cases the tranquilliser seems to aggravate the depressive state. If you

notice that the patient cries more easily, seems disoriented or even more 'down' than before, hurry up and consult the doctor.

A final recommendation. Sometimes tranquillisers produce what is called a 'paradoxical effect'. Instead of calming the patient, they induce exactly the opposite effect, namely restlessness and agitation. The person is unable to sit still for a moment, has fits of trembling, and cannot in any way find rest. His organism becomes like an accelerated engine trying to take off. This reaction is called akathisia. If it occurs, stop taking the medicine, and the akathisia should resolve within twenty-four hours. The doctor should then prescribe a different tranquilliser.

If akathisia appears, the greatest danger is the patient's reaction. He will develop a frantic need to regain his composure. Consequently he may be induced to take increasing doses of the same tranquilliser, which of course has the opposite effect of making his condition worse and worse. If this happens, it may be necessary to stay in hospital for a day or two until the episode is over.

Stimulants: precautions

As I mentioned in Chapter X, these substances are sometimes prescribed in cases of mild depression, or to help overcome occasional fatigue.

In some cases they are prescribed for delayed (slowed) depression, if the doctor expects the emotional disturbance to resolve within a few weeks. The main advantage is the injection of energy that the endogenously depressed patient receives when he or she takes a stimulant tablet in the morning when he or she wakes up, so that he or she can start the day in the best possible way. However, the patient should not take such drugs after four o'clock in the afternoon, as this may disturb sleep.

It is also important to avoid taking stimulants continuously for too long. They have many contraindications. Firstly, they can 'cheer up' the person without this being accompanied by an improvement in the depressive state. Secondly, the patient may rely on them too much; as the effect diminishes over time, larger and larger doses are required, with the result that the drug becomes a real drug. Thirdly, stimulants interfere with judgement, which is why anyone in a position of responsibility should avoid making important decisions while under the influence of the drug, which can lead to restlessness and irritability without the person realising that their behaviour has become so unpredictable that they pose a threat to themselves and others. Fourthly, if taken for too long, stimulants can induce a toxic reaction, which in turn can cause serious psychological damage.

You will realise that the stimulant drug has negative effects if the patient experiences flushing of the face, rapid breathing, and a noticeable loss of appetite. Other symptoms may include attacks of dizziness, palpitations and stomach upset.

Sleeping pills: precautions.

One of the first concerns of a doctor dealing with a depressive patient is to ensure sufficient rest and sleep, especially when the main symptoms are agitation and insomnia. This is because the nervous system must be given the chance to slow down and repair itself. Therefore sleep-inducing drugs are often indispensable in depressive states.

You should not be surprised, however, if your doctor stops taking them after a few weeks, and lets you sleep on the antidepressants alone (in a more natural way); or if he suggests only a tranquilliser before going to bed to promote the relaxation that precedes sleep. This is because sleeping pills, like many other drugs, can be addictive. You will notice this addiction when the patient begins to

manifest a feverish and irrepressible need for the sleeping pill, and only with it can he sleep. However, there may be other factors that you are not aware of that have contributed to the onset of insomnia - factors that can be eliminated, thus changing the situation of dependence on the sleeping pill. For example, your family member's sleep may be impeded by a switched-on television set or the noisy hobbies of a housemate. You should therefore eliminate such disturbances. Also look carefully at other possible disturbing factors. Is the patient's bedroom quiet and peaceful enough? Does it provide sufficient privacy? Is the bed comfortable enough? Does it allow the patient to rest in the morning without being disturbed? I ask these questions because when the family relies exclusively on sleeping pills, even if prescribed by a doctor, they often overlook negative environmental factors that could easily be remedied if they bothered to do so. And often, once these factors are changed, the need for the sleeping pill disappears.

Should medication only be taken with meals?

No, although many believe that medicines work best when taken immediately after a meal. It is true that doctors often prescribe to take them this way, but not so much because the medicine works better, but rather because it is a better way than others to have it taken at a specific time. Some drugs (especially those intended to treat the gastric and digestive disorders that often accompany the depressive state) should indeed be taken as prescribed before or after a meal in order to achieve the optimum effect. Other drugs, however, such as antidepressants, stimulants, tranquillisers and sleeping pills, should be taken according to the rate at which the substance is absorbed into the body.

If, for example, experience has taught you that in the case of your family member a certain sleeping pill takes an hour to work (i.e. the absorption time is one hour), and if he has to be asleep by ten o'clock in the evening, he should take the pill at nine o'clock.

In the case of antidepressants, we know that the substances they contain only take effect as long as there is a sufficient concentration of the drug in the blood. In order to maintain this level of concentration, the doctor may, for example, prescribe a pill every five hours; and consequently the time table will be one pill at eight in the morning, one at one o'clock and one at six in the afternoon. What if the patient sometimes sleeps until nine o'clock? In this case the schedule can be shifted by one hour, i.e. one pill at nine, one at two and one at seven, without changing the level of concentration of the drug in the blood.

What does this supervision task imply for you?

It should involve a new awareness of the fact that medicines can only help the patient if they are used in the right way; but that if they are used incorrectly, excessively, or otherwise than prescribed by the doctor, they can cause serious harm. It may be a good idea to memorise or write down the names of different drugs, rather than referring to them as 'yellow', 'blue', 'pink', 'small', 'round' or 'oval'. This way, if you are confronted with problems, especially if you talk to the doctor on the phone, you do not waste time trying to make him/her understand what the medicine is. You and the doctor will know, without any possibility of error, by knowing the name, what you are talking about.

It may seem to you that it does not take a great deal of brainpower to follow a medication-based treatment. That may be so, but it does not mean that you do not have to apply the closest supervision, all your intelligence and all your desire to help.

For example, it may be that one fine day your family member is feeling so well that he cannot see why he cannot stop taking the antidepressant. However, the improvement is probably due to the very medication he or she is taking, and certainly does not mean that the illness has already been overcome. This is why you should never agree to such a decision, as it could be a very serious mistake, since very often a relapse follows the discontinuation of the medication. If for

some reason you are unable to get in touch with the doctor immediately, continue to ensure that your family member takes his or her medication regularly, even if this means having him or her take it in your presence each time. This may be necessary so that the patient does not obstruct his or her own healing process.

Stimulants, tranquillisers and sedatives are prescribed for particular reasons. As back-up drugs to antidepressants or other drugs (or to physical therapy or psychotherapy), they are used for their specific effects in relation to certain symptoms. As soon as these symptoms seem to disappear, if the patient expresses the intention to try to go on without these 'crutches', they can be discontinued.

However, even in the case of these ive medicines, it is always necessary to consult the doctor before any change or discontinuation. Tell him or her what you think the of the problem are, but let him or her decide what to do, whatever you think and whatever the patient says.

There can be only one exception to what I have said above - that is, in the case of a drug which gives rise to effects that are visibly too strong, harmful, or which the patient cannot tolerate. In such cases, if you cannot get in touch with the doctor, stop taking the drug until you can reach him or her for further instructions.

The same applies to treatment for less serious cases. For more serious cases, the doctor will talk to you about the possibility of hospitalisation and physical treatment. In particular electroshock therapy. This is obviously a chapter to be dealt with in a very close relationship between the psychiatrist and the family.

XII. PSYCHOTHERAPY

The word 'psychotherapy' has now become part of the vocabulary of the man in the street, and I am sure it is a fairly familiar term to you too. You may have heard it referred to as 'conversational' treatment - that is, a method of solving a patient's problems through discussion, i.e. a conversation strictly about those problems. You may see it that way, but there is certainly more to it than that. Before explaining the use of psychotherapy with regard to depressive illnesses, I would therefore like to give you a definition.

What is psychotherapy?

A general definition is that psychotherapy is a process by which a person learns (1) to analyse his or her own value system, needs, judgement criteria and behaviour (and those of the people and social environment around him or her); (2) to understand them, so as to resolve anxieties, doubts and conflicts related to these factors; (3) to act on the basis of this understanding with the aim of a more satisfactory adaptation to his or her life context.

In short, the psychotherapeutic method of achieving such results consists of the set of techniques employed by an individual in order to influence the thinking, emotionality and behaviour of another individual.

Take, for example, the case of a nervous and slightly depressed young man who is insecure about the way he approaches his work, but unable to broach the subject with his supervisor. He is afraid of appearing weak, competitive or 'strange' and of making more confusion than anything else. He broods over these things and is irritated by his lack of courage.

At the end, he/she talks about this situation with a friend or family member whom he/she holds in high esteem. This could also be you. You then tell him/her what you think he/she should do, and how. He follows your advice, discusses the matter with his superior, presents him with the ideas you have helped him to develop, and everything falls into place. If we see this episode in the stages that made it up, we see that several things happened:

(1) Your family member has made you take on the role of the therapist (i.e. someone who can help him/her), and you have accepted this role.

(2) Since he trusted your good sense, and you on the other hand were willing to help him, a relationship was established between you (on the basis of mutual trust and goodwill).

(3) This relationship has become the basis for mutual iteration for a specific purpose.

(4) By listening with empathy and showing your understanding, you encouraged him to communicate his anxiety, to examine it, and to consider the pros and cons of the problem.

(5) You provided him with advice and direction, and this, together with your emotional , helped him to mobilise his resources.

What you did was to give him a "psychological hand" to help him reorganise his way of thinking, to take certain decisions, and to take a certain course of action

that would give him security. The result of all this was that he felt better and gathered sufficient strength to face the interview with his superior. An episode of interchange like this could be considered a condensed form of psychotherapy, which from a technical point of view included the factors of emotional relief, and guidance.

In most cases, however, 'friendly advice' does not achieve the desired results, for the simple reason that it tends to be undermined by the subjective factor. The friend or family member being used advances his or her beliefs and values to impose them on the other person. What he actually says is this: 'Listen to what I would do. It worked for me, and it might work for you. But to follow such advice would be like taking someone else's anti-depressant pills. If you are lucky, they may do something to you. But generally they will not prove to be effective. Advice from friends is necessarily something of a jackpot, and is not necessarily of any use for the needs of the person in need.

The professional psychotherapist, on the other hand, will always be objective. Neither his prejudices nor his personal inclinations play any part in the therapy. What he focuses on are only the needs of the patient and the strengths that can overcome the depressive state. This requires experience and great flexibility, combined with knowledge of techniques far beyond the reach of the 'amateur'.

PSYCHOTHERAPY IN STATES OF DEPRESSION

The therapist sees the patient once or twice a week, for sessions that usually last between thirty and forty-five minutes. The patient may keep in touch by telephone, and on occasion also in writing.

In the following pages, I will give a short summary of the most common psychotherapeutic techniques applied to patients suffering from depression. The

therapist can use all of them, or just some of them, with the possibility of combining them according to the case and the moment.

Emotional

When the person is in a state of complete despondency where anxiety and fear have absolute predominance, emotional becomes a therapeutic agent of primary importance. In the depressive state, the normality of others is a heavy burden for the patient; but when the patient feels accepted by the therapist, the moral boost he receives helps him to give back a sense of his own dignity.

This kind of is one of the most important prerequisites for recovery, as it contains the factors of encouragement and reassurance with a revitalising effect. This gives the depressed person the strength he needs to overcome his fears; for example, to venture back into a crowded shop, to find the voice he needs to answer an important question, to resume a certain social life (even if only marginally), or even to cope with the burden of his daily work. In this way, he no longer feels the humiliation of feeling incapable or inferior to others.

It is not uncommon for the person to feel a reduction in his emotional burden at the very moment of the first appointment with the psychotherapist. The acquisition of the knowledge that there is someone who "knows what to do" and who will him in his moments of despair is for the patient an immediate comfort factor. Anxiety decreases as soon as he feels that he is no longer alone in his struggle.

In the course of the therapeutic relationship, the patient gains a new sense of strength from knowing that his or her therapist is always available in case of need; and that during the course of the sessions every change of expression and every inflection of the therapist's voice denotes a great interest in their well-

being. Other patients are relieved to know that they can pick up the phone to get a word of encouragement from the doctor, should they fall back on their fears; just knowing that they can do this is a balm for their nervous system, even if they don't actually phone. One of my patients took advantage of the benefits of modern technology and tape-recorded some of our sessions, which she listened to in times of crisis for help and comfort.

The emotional of psychotherapy is rooted in the relationship between doctor and patient. "When a good relationship is established, such can work wonders. At the same time, this factor is the cornerstone of any psychotherapeutic procedure that aims to infuse the patient with new courage, rebuild his optimism, and recreate his social and work interests.

Liberation

When the psychiatrist speaks of what might be called 'psychic liberation' he uses the term catharsis. It could also be seen as a kind of confession. Whatever you want to call it, however, if your family member finds the right person to whom they can confide what is oppressing them, and manages to free themselves in this way, the weight of their emotional burden is considerably reduced.

Perhaps you do not realise that the depressed person experiences this heavy contradiction: he or she 'keeps everything inside' (especially guilt), but at the same time has an extreme need to expel what makes him or her feel bad. Other family usually fail to grasp this point. Let us suppose, however, that one of the family , who is particularly sensitive, is able to perceive this repressed anguish, and expresses (albeit vague) sympathy. Without this being his intention, such a demonstration of sympathy causes the depressed person to start talking about what is worrying him and troubling his mind. Soon, however, he seems to be just rambling: the other is naturally bored, and shows it. When the depressed person realises this, he inevitably shuts up and becomes even more withdrawn.

In psychotherapy, however, the therapist is aware of these inner barriers. His main aim, then, is to induce the patient to open up, to 'let go'. The therapist is there precisely for this - to understand as much as possible the patient's sense of guilt and confusion; and beyond that, to direct all the material discharged by the patient into more constructive channels.

For example, I frequently deal with parents of teenagers who react with guilt and mild depression when their children drop out of school, take drugs, or lead sex lives that are not in line with their principles. What has happened is that parents have received from various sources a self-image that seems hateful to them, to the point of believing that their children's shortcomings and seemingly aimless lives are entirely their own fault, without understanding the cultural factors at play. They therefore desperately need to 'talk about their faults'.

I a mother who barely said hello to me and sat down before bursting into tears. Her daughter was displaying impatient and rebellious behaviour. She began to blame herself, telling me through her tears how guilty she felt for having gone back to work years ago, when her duty as a mother would have been to stay at home to take care of her child. "I was never a good mother, was I?" she cried. "It was all my fault."

Once she had expressed her feelings of guilt and released her emotions in this way, she was in a better position to consider the objective of her problem, to answer for herself the questions that had come to her mind, and to recapitulate the circumstances of the period she had told me about. She began to recall her husband's financial difficulties, the need for additional family income imposed by the birth of her daughter and the needs of her husband and herself, who were still very young at the time. In the following sessions other memories surfaced: all the precautions she had taken to ensure the child's care in her absence, the hours she and her husband had devoted to her, the intimacy, the cheerfulness and the warmth that, thanks to her, reigned in their home.

Her feelings of guilt disappeared when she was able to recognise the economic necessity and sheer need for survival that would have made any choice other than going back to work irresponsible. In other words, psychotherapeutic liberation offered her the opportunity to bring events back to their true proportions and within the objective framework of the past situation. The consequence of this was that she was able to come out of her state of despondency, and was able to discuss rationally how she could now be of help to her daughter.

Another patient of mine, suffering from mild to moderate involutional depression, had symptoms including recurrent feelings of guilt about her father. His father had died a few months earlier, and for many years my patient had had to give him daily morphine injections to relieve the pain of an incurable disease. Now her depressive state meant that she was 'certain' that she had criminally carelessly istered a lethal dose on the day of his death. Not daring to reveal her doubts to anyone, she had for some time nurtured the firm conviction that it was she who had caused her father's death.

When she was finally able to put her suspicions into words, her feelings of guilt diminished. She was led to return to the days of her father's illness, to his slow decline and the terminal phase during which only higher and higher doses of morphine could ease his suffering; and finally, death. Having regained his composure and clarity, he recalled that each increase in dosage had been prescribed by his doctor. She even ed the detailed instructions the doctor had given her, the way he prepared the injections, the doctor's words of confidence, and his praise for the way he was taking care of her father.

To complete the picture of her recollections, she finally telephoned her father's attending physician from my office. The latter, after checking his records, confirmed every detail of what my patient had told me, down to the dose of the last injection. When she finally realised that the 'fatal mistake' had not actually happened, she was free from her tensions. The response to the treatment was

immediate in this case, and the depression was soon overcome.

When the person in the sanctuary of the psychotherapist's office can give free rein to the thoughts and emotions that are troubling them, and receive indulgence and empathy in return, a true rebirth occurs. I have seen many patients 'reborn' from the relief they felt after confessing their most disturbing secrets - one man overwhelmed by the self-loathing he felt because of a constant desire to hurt his wife; another who fell prey to depression because of the shame he felt at having abandoned religion; others troubled to the depths of their being by the need to hide family or business secrets; a woman overwhelmed with guilt because of the hatred she felt for her lazy and mediocre son ("It's not normal for a mother to feel things like that, doctor... He's my son, and I don't like him. He's my son, and I don't like him. There must be something wrong with me').

Such confessions are good not only for the soul, but also for the body, because guilt, fears and obsessive ideas can poison the body just like toxic substances. Once the person has freed himself from these poisons, his mind clears and he is able to shake off his depression and face his problems more objectively.

Directive therapy

In the case of a depressed person who can no longer make decisions or take any course of action, the first measure to be taken is so-called directive therapy.

When caring for elderly or partially senile patients who are unable to organise themselves, it is necessary to plan their day so that they are provided with care and activities. Their freedom from depression depends on the extent to which we can keep them occupied, offer them a precise programme and entertain them. Due must be taken of the fact that activity in itself puts the body and mind to work, stimulating the blood circulation, muscles, brain cells and the

whole organism, and thus prompting the person to undertake new activities on his own initiative. Directives aimed at this and the resulting revitalisation often induce an improvement that neither medicine nor any other form of treatment can achieve.

The directive therapy also achieves very good results in the case of light and moderate depressions that only immobilize the patient temporarily. The first thing to do is to show the patient how he can objectively assess the extent of the stress that is oppressing him; then it is explained to him how he can circumvent or overcome the stress.

Instructions of this kind are given in plain and unambiguous language; the patient is told, for example, what he should say and what he should not say to a work colleague who delights in teasing him; how he can deal with a teacher or a parent without raising unnecessary conflicts; what the elementary rules may be for spending an evening in company without incident; how to plan his daily work now so as to keep up with the pace despite the difficulties of the period he is going through. In this way, the patient is offered a 'storehouse' of directives from which to draw in the various contingencies in which he may find himself. Later on, once he has become more flexible and the depression has disappeared, he can adopt these guidelines as his principles of conduct and make them his own.

The doctor practising directive therapy needs tools that go beyond the narrow field of psychology. He must have at his fingertips a whole range of knowledge relating to various fields of interest, as the urge of the depressed person to acquire it himself is too weak. Such information will include employment agencies and organisations with which the patient can get in touch; the exact in which to fill in a job application or a curriculum vitae; who can be ed to organise the wedding of the patient's daughter, when this task is too heavy for him to carry out himself; where one can take a cookery course to entice a husband with "eating the way mum used to eat"; a pleasant holiday resort for a lonely and sad young woman, and where she can turn to solve her

clothing and make-up problems in order to enhance her charm... And while the doctor may not have the answer to every question, he knows who does.

An example. A young black man living in the ghetto area fell victim to chronic depression. His mother, a cleaner by trade, had managed to keep him in school until he graduated. In his free time, and full-time after graduation, the young man worked as an errand boy for a grocer. Because of his depressive state, his doctor recommended psychiatric treatment.

Through directive therapy, the young man was ed and encouraged to embark on a goal-oriented job search campaign; and since the main symptoms of his depressive state included insomnia and sleep reversal (awake at night, asleep all day), it was suggested that he look for a job at night. Although he was sceptical about his real chances, he found a job as a data analyst (including training period), as he had asked for the night hours for which there was a shortage of staff. He later managed to get a better, well-paid position, and needless to say, depression and insomnia were now a thing of the past.

By establishing a precise aim and course of action, which is naturally within the patient's reach, the therapist prevents him from getting bogged down in deciphering his own desires, motivations and doubts. Depression would keep him in a position of perpetual checkmate; instead he can place his trust in the therapist's judgement. Directive therapy helps the person to set out on the path to productive goals; and this relieves the burden of the depressive state.

Suggestion

In psychiatry, suggestion is the art of introducing effective ideas into a patient's way of thinking. This can be achieved by means of an 'oblique' tactic, which is particularly effective in the case of people who manage, once they have received

the suggestion, to put their constructive abilities to work. Such people are what we might consider, when they are well, positive and perhaps dogmatic individuals. They do not respond well to a directive approach, as they tend to become rigid and resistant. But when they are led to believe that a certain course of action is essentially their own idea, they will have no difficulty in taking it.

Suggestion has effective results in various areas of the person's life; it can instil in him the courtesy and good manners that are a prerequisite for dealing with others; it can induce him to greater discipline at work; it can teach him to turn weaknesses into strengths. It is a particularly good method for introducing new aims and values into the consciousness of the depressed person.

A patient of mine had retired from a chairmanship in a large industry and his inactivity had proved so burdensome that he had become (reactive) depressed. He was reduced to living in a state of suffering and inebriation; he felt that life had abandoned him and that there were only long years of absolute emptiness ahead of him. As we proceeded to examine his feelings, he became more and more aware of the fact that he was lamenting a "loss" (that of work). But it was not prestige or money that he was missing. "It's just that I no longer feel useful". He recognised that he still had talent and energy, but did not know where to put it: the world belongs to the young, you know. All the experience and wisdom he had accumulated over the years was worthless if no one needed it. "That's why I'm here talking to you, Doctor. It's not that I feel bad - it's that I'm depressed. And being here helps me to think about something else. You act like I'm an interesting person to me. And the medication helps me too.

He began to ponder aloud how his ambition seemed to have evaporated since the day he retired. Some time earlier, for example, before he left the company, he had bought a large plot of land in a prime location, not far from where he lived. At the time he had considered turning it into a golf course.

One day, before he came to my study, I put a newspaper clipping on my desk so

that he could see it. We talked about his problems for a while until his eyes fell on the article. He read it over and over again - it was a story about a summer camp that had been organised in the Middle West for families who could not otherwise afford a holiday. My patient continued to study it intently, and when the session was over he asked if he could keep it.

The next time, there was a certain enthusiasm in his eyes, for the first time in weeks and weeks. He explained, his face brightening, that he had kept thinking about that piece of land. Why not build something like the place mentioned in the article? There were too many golf courses, so why not do something more useful? It had occurred to him to go down there, study how they had set things up, and maybe try to do something even better. "With everything I know about running a project from start to finish, I can't not do it. So it happened, and within a year the camp became a reality. My patient became the istrative director, and soon it was going well. When I saw him for the last time, he said, "Wasn't it lucky that I came up with that camping idea that day in your office? It was the best idea I ever had. I've never had so much fun. I feel ten years younger." And when you look at it, you do.

In another case, the mild depression of a young woman who came to me was caused by the presence of her mother-in-law, a retired schoolteacher, who was ruining her marriage with her veiled insinuations and jibes. The result was a situation of violent conflict between the two women, while her husband, a fragile and insecure person, had withdrawn into a position of complete neutrality. "He treats me like a third grader," my patient repeated. "Whether I'm sewing curtains or changing the baby's nappies, he always has something to say. He sticks his nose into everything I do."

When her depressive state had improved somewhat, I suggested that perhaps she could persuade her mother-in-law to engage in some activity that might divert her attention in other directions. What? Well, for example, getting her involved in some hobby, like painting; if she bought her paints, palette and brushes, and offered them to her as a gift of peace, maybe the situation could change. "You

mean keep her busy so she'll give up on me?" "Something like that." She told me she would try, though she didn't sound very convinced.

After buying the material, however, she did not feel like giving it to her motherin-law as a token of appeasement, as she did not feel at all sure of the result (which was more or less what I had anticipated). Instead, she began to tinker with paints and brushes herself; with some encouragement from me, she moved on to charcoal sketches, and eventually turned to sculpture. Before much time had ed, she had become so absorbed in this new activity that both her mother-in-law and the Depression were excluded from her life. She devoted herself more and more to art, and today some of her works are exhibited in the offices of the bank and the electricity company in her town; and everyone gives credit to her mother-in-law!

The weapon of suggestion thus proves to be a first-rate therapeutic device in the case of persons who can be subtly manoeuvred into new fields of action. In this way, the impression is given to the depressed person that he has set the goal himself and has made the decision independently, whereas the therapist has apparently merely given his approval.

Explanatory therapy

When the patient's thinking is so weakened and blurred that he cannot focus on any object, and his memory is no longer reliable, he begins to doubt his sanity. It is then that a therapeutic procedure based on clear explanations of his state becomes expedient, which, coordinated with other therapeutic methods, makes it possible to relieve the patient's state of agitation and gradually to bring him back to the full possession of his faculties.

In endogenous depression the patient feels confused and out of place. This

condition terrifies him, and he demands to know 'what is wrong with him'. In such cases the explanation of the link between the imbalances that have been established in the delicate chemical mechanism of the brain and nervous functions and the depressive state can greatly relieve the patient of his fear of the unknown. Often, indeed, anxiety and agitation are replaced by curiosity. The patient is so eager to know what exactly is going on in his body as he proceeds towards recovery and is so absorbed by the answers he is given that he forgets all his fears.

In the case of a grief reaction (culminating in the depressive state) the person may be fully aware that the illness has been caused by a loss, but nevertheless be alarmed by the symptoms he or she is facing. The first explanation will then deal with the normality of such a reaction, and its predictable duration. Then it will be explained to the patient what has happened to him by virtue of the stress induced by the loss. He is shown how the human being needs to depend on the outside for his survival, and how consequently severe deprivation can cause extreme disorientation; life can then seem such an unbearable burden that the individual is overwhelmed by the psychic fatigue of the depressive state and is blocked, even if temporarily.

When the person comes to understand the phenomenon of the grief reaction, he can then objectively assess the strengths and values he still has at his disposal; and once he is able to make effective use of those strengths, he can gradually overcome the loss and the resulting depressive state.

In neurotic depression the person generally fails to realise that his or her reserve of adaptive energy has been exhausted, and that this is the reason for his or her inability to cope with human relationships and his or her usual tasks. But when the process of adaptation is explained to her in of stimulus and response and in of individual reactions and counter-reactions to life's conflicts, the mystery surrounding the symptoms is removed, and with it much of their intensity.

Even if the patient is not always able to grasp all the technical details of the matter, his fears are alleviated by the fact that he now knows that there are explanations; the patient needs these explanations because the explanation means that the disease is not an individual and unexplainable enigma, and that it can be treated and cured like any other disease.

A precise explanation not only provides information, but also fosters an attitude of trust in the patient, renewing what is most essential for every depressive, what he needs above all else: hope.

Behavioural therapy

A procedure that aims directly at re-educating the patient for a more satisfying life can be called a conditioning process. This type of therapy can be used to educate the depressed person, to provide him with new incentives and to make him more optimistic about life. This type of therapy is also useful for patients with mild to moderate depression of reactive or neurotic origin, and as an additional or ive therapy for anyone who has difficulty adapting before, during or after a depressive episode.

Behavioural therapy employs learning techniques and the principles of conditioning to teach the person to change the attitudes, traits and behavioural characteristics of the maladapted personality. For example, the patient will be taught how to relax and avoid outbursts of fear, anger and panic as long as the depressive state persists; he/she will then be enabled to express his/her innermost feelings in order to dissolve the depressive state. The ultimate aim of this type of treatment is to get the patient to overcome his neurotic patterns, so that he can no longer fall victim to nervous breakdowns and the depressive state.

The neurotic depressive of the obsessive-compulsive type offers particularly

fertile ground for good results through such therapy. Such people are literally 'rebuilt' when they learn to be more elastic in order to adapt to the twists and turns of life. Victims of an obsessive need to control their every action, forced to return to it over and over again, often respond to the conditioning process much more quickly than to any other psychotherapeutic technique; they will be taught, for example, to walk more often and longer on the right-hand pavement, when their compulsions would drive them to walk on the left; to refrain from returning to the door over and over again to make sure it is closed; to stop counting the items in their shopping bag; to suppress from the beginning any new possibility of obsessive actions.

Behavioural therapy breaks down rigid patterns of behaviour and helps the person to find new life patterns, just as certain physical exercises can transform weak bones and stiff muscles into the supple and flexible tools of new activities. This process eliminates the roots of the depletion of adaptive energy that leads to depression.

Environmental manipulation

It is a procedure that aims to find or create an environment in which the patient can live and to which he can adapt without wasting his energy and without testing his regressed nerve functions. One could say that it is simply a matter of changing his physical and social environment. But the results are anything but simple, since what is achieved is a modification of every structure of the personality and every pattern of development of the individual. The purpose of such a modification of the environment is to reduce the stress factors weighing on the sufferer to the point of taking a toll of energy beyond his ability to bear.

The therapist, for example, can persuade the family to alleviate those conditions in the depressed person's life which drive him or her into ever greater isolation. This means that it will be necessary to provide him with a quiet room, separated from too noisy and turbulent environments, in order to avoid any factor of

excessive nervous excitement. Or, in a broader perspective, especially in the case of neurotic and chronic depression, the patient will be persuaded to change his job to one of lesser responsibility, or to enrol in a university faculty where the competition is less severe, or to move to a place closer to his place of work, A change of environment which may be necessary to save the patient's life itself is the hospitalisation of the severely depressed person in order to protect him from his agitation or suicidal intentions. In this case the manipulation is intended to avoid self-destruction.

"Travel therapy

This type of change of environment is a tactic that can be usefully employed in the case of mild depression caused by excessive fatigue or a recent event with a depressing effect. The distraction of the change of scenery will then be the only treatment needed. This is particularly true for people suffering from neurotic depression who periodically need to regress to 'holiday' patterns of behaviour without the burden of usual worries. It is an escape valve that can provide some relief; and it is certainly preferable to a potentially explosive situation that can result in a major depressive episode.

I would like to add something about the negative aspects of 'travel therapy'. If the person is going through an episode of acute depression, going on a trip is of little use; a holiday at this time can even be harmful, when the person realises that he or she is not able to enjoy the sun, sports and entertainment as much as everyone else. What's more, she will continue to suffer from insomnia, not enjoy food, and will not be as cheerful as usual. She will have done nothing but bring depression on herself even at the holiday resort, and will continue to feel deeply unhappy. In such cases what is required to repair the nervous system is active treatment, not rest.

Group therapy

All the psychotherapeutic procedures I have described in the previous pages can also be practised profitably in a group setting of up to ten patients.

Group therapy is particularly suitable for the chronically neurotic depressive. Not to mention the lower cost of such a therapy, in this way the patient is forced to see himself in relation to others. He can then recognise and evaluate his strengths and weaknesses in relation to other people in the same condition. He will also find an immediate response to many of his needs: he will discover that he no longer has to face the illness alone, and that the group will him emotionally, encourage his every effort towards improvement, and ire his strength of character in not succumbing to self-pity.

He also grows in stature as a person, because he learns to give something to others in their difficult moments; and this helps him to reshape his tendencies to wallow in his own despair. In the group, it is easy for him to see that others are in the same situation as he is in ('if they can get out of it, so can I...'). Group therapy can be combined with any other type of antidepressant treatment. However, I would like to make one recommendation: those suffering from moderate to severe depression should avoid highly demanding programmes such as group marathons, encounter groups and the like. The emotionally debilitated individual needs , and his tolerance thresholds are too low to tolerate experiences such as many of the latest group therapies. Only the psychiatrist can possibly authorise participation in such experiences.

Family therapy

This is a special type of group therapy, in which the group consists exclusively of of a family group. Recently, there have also been experiences of multi-family therapy, where several patients meet with their families.

Family treatment is especially effective when a key family member suffers from chronic depression, and the illness tends to disrupt the emotional set-up of other family , resulting in a situation of upset and mutual hostility. Family therapy may then be the right answer. In this type of procedure, the patient and a large and particularly significant portion of his environment are treated simultaneously, in the hope of achieving through group work a satisfactory rapprochement between the family , teaching each to exert less pressure on the crucial point represented by the depressed person.

Other psychotherapeutic procedures

There are also other important psychotherapeutic techniques, in addition to those I have already described, which you have probably heard about. I will mention them briefly here.

Interpretive psychotherapy

It is a very complex and highly intellectual method that explores the symbolism of communication and the role played by symbols in the functioning of the individual psyche.

The aim of this procedure is to give the person the ability to penetrate his own motivations - so that, for example, he can understand the value and meaning of his self-image and behaviour in of symbols such as the car he has bought himself or the area in which he has decided to live; the significance of an insult as a threat to his (symbolic) survival; and the true meaning to be attached, beyond appearances, to his likes, dislikes, and desire for attention and recognition. The emphasis here is on the whys of ideas, feelings and behaviour,

through the analysis and interpretation of dreams and conscious speech. The assumption is that the patient can derive great benefit from therapy if he learns to interpret these symbols himself, and to change his life patterns in accordance with this interpretation.

I personally use this type of therapeutic approach only for the treatment of personality disorders other than depression. Occasionally it can be used, in combination with drug treatment and explanatory psychotherapy, in cases of mild depression of reactive and neurotic origin, but it is of no use in treating patients suffering from endogenous depression, or other severe or acute forms of depression.

Psychoanalysis

Psychoanalysis is the classic method of interpretative therapy (in which the tool of free association is employed: the patient lies on the couch and talks about whatever he wants). It is based on Freudian theory, which interprets neurotic disorder in of the unconscious, innate libidinal instincts and psychosexual development, and explains how these forces give rise to fixations and immature levels of development of personality structures in such a way as to cause neurotic conflicts and other difficulties.

Most of my Freudian and neo-Freudian colleagues, however, agree that psychoanalysis is too demanding and prolonged a procedure to treat depressive disorders effectively, especially if they are in an acute form or if they are characterised by extreme agitation. The spokesmen of the psychoanalytic schools recognise that the pace of social change and medical development has accelerated to such an extent that psychoanalysis, as a therapeutic procedure, needs profound changes in theory and practice in order to provide the shorter therapeutic procedures that will enable depressive illness to be treated effectively.

Those psychoanalysts who have worked in clinics and hospitals and have witnessed the rapid improvements in depressed patients following short-term psychotherapy have been enthusiastic about this method and very satisfied with the results.

XIII. YOUR ROLE IN PSYCHOTHERAPY

When the doctor suggests this type of treatment for your family member, the first question you might ask yourself is: "What form of psychotherapy is best suited to depression?".

There are so many theoretical approaches to psychotherapy, each based on different concepts, that a certain amount of confusion on your part is entirely understandable. There is, however, one fundamental premise: in the treatment of depression, it cannot be said that there is one procedure that is better than all the others, or that one type of psychotherapeutic approach can be applied to the exclusion of any other. Rather, the parameters to be considered should be: first, whether the procedure in question has the means to deal effectively with the ever-present danger with depressed patients - of suicidal intentions; second, whether it can offer the patient prompt relief from his symptoms; third, whether it can get him out of his state of despair, enabling him to stand on his own two feet as soon as possible in order to fulfil his potential, achieve his aims and enter into satisfactory social relationships. As I mentioned at the end of the previous chapter, there is a known agreement between psychoanalysts and nonpsychoanalysts that in the treatment of depression, short forms of psychotherapy are the most appropriate.

The questions that you have to ask yourself first are therefore these: Does the doctor have the experience and the tools to diagnose the illness and free the patient from the inhibitions of depression and the idea of self-destruction that torments him? Does he possess the qualities of humanity and intuition needed to establish a relationship that is capable of ing the patient in the worst moments of the illness? Is he able to re-educate the person by providing new and better criteria for judgement, so that he can face life without falling victim to conflict? Does he/she have sufficient experience and authority to the actual needs of the individual, changing his/her environment if necessary, and

thus helping him/her to overcome depression? Will he/she be able to overcome his/her depression by convincing and encouraging him/her to take certain decisions and act accordingly?

Another question may come up at this point: how can you, a layman, answer such questions? One way is to make a certain enquiry (see chapter XVIII) about the psychiatrist or therapist the patient would like to consult. Another criterion for judgement may be your own (or the patient's) impression of the therapist during a preliminary meeting. In this way, you will be able to know whether the doctor confines his interest (for reasons of preference or training) to a particular theory and method, or whether the perspective in which he puts himself encomes every aspect of psychotherapy and social awareness corresponding to the patient's actual needs, and can thus help him to overcome depression.

Is psychotherapy alone enough?

Provided that the emotional disturbance is only minor, and not complicated by endogenous factors, psychotherapy may succeed in mobilising your family member and re-establishing normal ego functions. But you must be fully aware that if the depression persists or worsens, the therapeutic programme will have to be reinforced by the use of medication and/or other types of treatment. In the most severe forms of depression, with the possibility of suicide attempts, psychotherapy alone will not be sufficient to cure the depression, although it may temporarily prevent suicidal gestures until other treatments can be employed.

I would also point out that in the course of the psychotherapeutic process, a change of objectives may occur. If, for example, the depressive state, however acute, is not serious, a short series of intensive sessions may suffice. If, on the other hand, the psychotherapeutic treatment reveals stubborn personality traits that constitute an obstacle to a rapid and full recovery, then the therapeutic goal will be altered, because personality structures and the depressive state are closely

linked and must therefore be treated together.

In such cases, therapy will have to be prolonged, and one must be prepared to overcome such eventualities.

When accompanying the patient to the psychotherapist

You should accompany your family member to the first psychotherapy sessions. Depression is a lonely and sad illness, and any act of encouragement on your part is at the same time an act of pity; in this way you are telling him that you wish to share his emotional burden with him, without intruding into his private affairs. Your physical presence on this occasion will make him feel loved and protected.

You should not be surprised, however, if at some point the doctor tells you that you no longer have to accompany the patient to his office. Instead, you should rejoice, because this will probably mean that he is testing the patient's ability to rely on his own strength. So when the doctor makes this suggestion, you should not only make the patient go to the appointment alone, but you should also encourage, listen and cooperate. In this way you will strengthen the effect of the treatment.

Will the doctor want me to comment on the patient?

It is likely that he will do so from time to time, but I would like to make a few things very clear. What you can use for therapeutic purposes is a factual of the patient's activities at various points in the treatment process, but not your own opinions. You should only report things that your family member has said,

or things that you have observed about his behaviour, how he has slept, how he has conducted his social relationships, and so on; but you should not try to interpret this data, or to rattle off a series of comments that are in fact no more than a summary of your concerns. Let the doctor assess the information you give him/her.

You cannot know, before you have tried, how much information you can condense into a short period of time. If you collect ideas in advance, your report will contain all the necessary information; you can also do this for the doctor's secretary, or for the social worker if the patient is treated at a clinic.

Another system is to send the doctor via the patient a written message drafted with the greatest economy of words.

But do not be so telegraphic as to condense everything into two or three sibylline sentences. I , for example, the case of the husband of one of my patients who seemed to have improved. So I asked him to come to see me, and asked him if the patient was now eating with more appetite. His answer was: "Not at all. Like a bird". This conclusion of his did not tell me anything I wanted to know. I then learned that for breakfast my patient had orange juice, a hot plate of cereal, bread, butter and jam, and tea. The other two meals were just as plentiful, but her husband considered them quite insufficient, since - as I later discovered - his eating habits were very close to gluttony. This is a striking example of what I have said about the subjectivity of the opinions of the patient's family.

with the doctor

You should call the doctor to report on your family member's progress whenever necessary. On the other hand, it seems to me a foregone conclusion that the

doctor, if he knows how to do his job, will certainly keep the patient's blood relatives informed of the progress of the treatment. If you have read this book carefully, I will not need to repeat to you how profound the effect of depression is on family life. You have every right to know "what's going on" with the patient's health, and if the doctor doesn't give you news, a phone call from time to time will not be out of place.

However, this does not mean that you have carte blanche to call the doctor at any time of the day or night. You should not overdo it, because then you will certainly be inconvenienced, no matter how many excuses you make each time (the doctor's time is always precious). Depression is not a high fever that can drop to normal levels from one hour to the next. The healing of your family member's ailments is a much slower process. If you find yourself calling the doctor before and after each session, try to think about it, and you will find that you have become so emotionally involved in your family member's illness that you are now asking the doctor to deal with your anxieties.

See doctor separately

Some doctors consider psychotherapy to be such a private affair that they absolutely refuse to see a relative of the patient. I have my doubts about the appropriateness of such a stance in the treatment of depression, unless the patient himself makes a specific request to that effect.

You may wish to consult with the 'same' doctor who is treating your family member because, as I suggested above, your family member's anxieties have been ed on to you, and you are looking for an opportunity to express them. So do not hesitate to make an appointment with your family member's doctor, even though you may have heard that 'it is not done'. It may be that some therapists feel this way, but most doctors are objective enough to be perfectly capable of treating two or more of the same family group involved in the same illness. In the rare cases where this may cause conflict (when, for

example, the patient is extremely possessive of 'his' doctor) the therapist will inform you of this and refer you to a colleague.

You would like to be the psychotherapist of your family member yourself

Sometimes you may have thought: 'Why couldn't I put myself in the psychotherapist's shoes, and advise the patient what I think he should do?

If such a thing has occurred to you, the first thing you should do is to discuss it with your doctor. I don't doubt your good intentions, but if you put yourself in the psychotherapist's shoes, you may find yourself resting on such unsound foundations that you may find yourself, as it were, beating about the bush, with results opposite to those you had hoped for.

Many relatives of depressed people raise this issue in an oblique and 'disguised' way. Intolerant of the depressed person, they toy with the idea of treating them by giving them (in their own words) 'a good kick up the backside'. In other cases, one of the family may unconsciously be competing (in of attention) with the depression, and would like to make the patient understand that his illness is just too much, and that he can no longer bear it. This conception of therapy is actually the expression of a request, namely that the patient please hurry up and get well 'before I have a nervous breakdown' (thus intensifying the patient's feelings of guilt).

If, on the other hand, the family member in question is a disciplinary fanatic, he or she may decide that the best psychotherapy is to intervene heavily and brutally (in accordance with his or her own value judgements) and whip the patient towards recovery. "Listen to me carefully. I want you to stop all this and decide to be a normal person. Start living like everyone else. I know you can do it. And immediately. Move!" The relatives of the depressed person should take

every care to avoid such approaches.

Some try to insinuate their 'psychotherapeutic' conceptions through the person of the doctor. In some cases they adopt the tactic of dropping their suggestions in the course of a conversation on more general topics. In other cases, they have not the slightest restraint in "teaching" him how he should treat the patient, or in suggesting certain medicines which "did so much good to the aunt".

A father once said to me: 'Why doesn't he just tell Mary to go out with her friends more often? She's always locked up. She says she's sick, but I assure you it's all an excuse. She's like an open book to me. Suppose I had suggested something like this to Mary. She would surely have said, with a half-smile on her sad face: 'My father must have said something to her'. Mary had been hearing things like that for years before she finally came to me. What her father couldn't even begin to imagine was that for some time Mary had been thinking seriously about the peace that dying would bring her. My first aim in her psychotherapy was to keep her interested enough to keep her alive. The possibility of going out with friends was reserved for a future that was not yet in sight. When I explained all this to the father, he still refused to acknowledge her state of depression, and said that as far as he was concerned the possibility of his daughter's suicide was completely meaningless.

So make sure you are aware of the real facts, consider them seriously, and try to understand what your actual intentions are before interfering with your opinions.

Follow the doctor's advice

Taking into what you have read in the previous paragraph, you can really help if you follow the treatment plan in accordance with the doctor's strategy.

If, for example, the patient needs more emotional than the doctor can provide in the course of two or three sessions a week, the doctor may ask you for help and explain how you can provide it. Or suppose the depression is reactive, due to a loss. The doctor may then ask you to spend more time with your family member, or explain how you can communicate your awareness of the severity of the loss to the patient. Family often feel empathy, but are hesitant to speak up, fearful of using the wrong words. And you have no idea how much a depressed person can be comforted by the verbal expression of your empathy, however uncertain and inadequate you may think it is.

The doctor may also ask for your help in getting the patient to follow his instructions. A young woman suffering from neurotic depression once confessed to me with great shame that when she was able to go out for a shopping trip to the shops in the city centre she was able for some time to recover her cheerfulness and good humour; the problem was that she was too afraid to go out alone, and at the same time the idea of asking someone else to accompany her on these little expeditions embarrassed her beyond measure, because she feared that they would consider her too frivolous, and more interested in clothes than in the house and children.

I telephoned her husband, and was amazed at his intuition. There was no need to insist. He immediately grasped the of the matter, and arranged things so that the wife had company for her outings, while the children were looked after by a baby-sitter. The wife therefore came back more relaxed each time, refreshed from her day of leisure and ready to take on some additional responsibilities. Without her husband's cooperation, I would never have been able to carry out this simple but important therapeutic diversion.

I also a young man who was very doubtful about the usefulness of working with me. His father was a sixty-eight year old widower, still running a shoemaker's shop that no longer made any money, but gave him a "place to go" every day. His two brothers had bought a house in Florida and had been living

there since they retired. They had repeatedly insisted that he them, but a slight depression had so far prevented him from making arrangements to go.

I discussed the matter with the son. The son was not convinced of his father's depression. "I think you are wrong. It's true that he loves his brothers, but I know that if he left the shop he would die. I suggested that perhaps it was just the opposite, and persuaded him to take his father to Florida for a visit; then, on his return, he could tie up the loose ends for the shop. In the end, albeit reluctantly, he agreed, especially since the uncles (with whom I had spoken) were on my side.

A few months later I went to Florida and had lunch with my patient. For the first ten minutes, he was full of complaints about "the way I had screwed him over". But as he spoke, something shone in his eyes every now and then, and in the end he could no longer hide his satisfaction at my skill. Today this man is in his seventies and is fully satisfied with his life as a pensioner with his brothers. If the son had not cooperated with me, the patient would have dragged himself into a state of chronic depression in a climate that was putting a strain on his physical and mental health.

Although it is true, therefore, that psychotherapy is a relationship between two people, the doctor and the patient, there are cases in which the family must also contribute. The doctor will be able to count on you to educate the patient to see his illness in a new perspective (as in explicative and directive therapy); to help him overcome his fear of bridges and tunnels (as in behavioural therapy); to the person without inhibiting him when he needs to 'let go' (as in liberating therapy); or to make your own contribution in any capacity. this is the part of psychotherapeutic treatment that falls to you.

If the patient plays the mysterious

Often, psychotherapy patients become increasingly reticent about their families. This can have various reasons. It may be the case that the person tries so hard to go into depth during the talks with the doctor that once at home he is too tired to return to the same topics. Or the problems raised may give the patient so much cause to feel that he/she is isolating him/herself from everything and everyone.

In other cases he may be so frightened by what he is revealing to the doctor that in the end secrecy is the only solution for him. I , for example, a woman who was desperate because she could no longer deal with her intrusive and hypercritical husband. My patient, a sweet and submissive person, was powerless in the face of his harangues. Nevertheless, she was always in love with him, because deep down he was a generous, sensitive and devoted man. Caught in this dilemma, she had exhausted all her energy trying to adapt to him and his outbursts, and had become depressed.

In the course of psychotherapy she was able to touch this conflict, and to express the thoughts of rebellion she had been harbouring for all those years. But once she had let it out, she began to worry about the possibility that she might carelessly express some of this to her husband. She solved the problem by not talking to her husband about her sessions at all. It was only when, after a further period of therapy, she was able to deal directly with her marital problems that she returned to the cheerful and affectionate person everyone knew.

As we proceeded with psychotherapy, the husband went through a period of anxious waiting, sure that he had lost her forever. But forced to wait, he learned to be much more patient and tolerant and began to appreciate his wife in a new way. A better relationship based on mutual respect and trust ensued, and what had seemed to him to be a severe trial turned out to be an opportunity to restore the marital relationship.

Sometimes, however, the patient's less communicative attitude means that he is waiting for the doctor to reveal to you what he himself does not have the courage

to tell you. It is quite common for the patient to "talk" to the family through the therapist, especially in the case of depressive states where the patient is possessed by ideas of unworthiness. Such people feel excluded from family life, through no fault of their own. The fact is that the person feels too humiliated to ask for the affection and acceptance of others, but at the same time wants it with all his or her heart. The therapist therefore assumes the role of a "third person", and by communicating the patient's needs to the other family enables them to dispel the patient's feelings of loneliness and estrangement.

When your family member starts to 'act mysterious' during psychotherapy, this often means that they are discussing emotionally charged material with the doctor, which may (or may not) include you. It is understandable that being shut out may be a blow to you; a parent or spouse may be shocked when the door is shut in their face. But you must try to avoid the counterproductive attitudes that I often see from my patients' relatives. Don't react by getting irritated, or indignant, or distant, or by looking the other way, and at the same time getting angry. Instead, try to put yourself in your family member's shoes for a moment. Think back to your own personal, intimate thoughts that trouble you from time to time - hidden anger, guilt, fear, despair, mistakes - and judge objectively whether you would feel comfortable communicating them to anyone other than your doctor. If you are honest, you will certainly answer "no".

So respect the privacy your depressed family member so badly needs during this difficult time. And while doing so, try to be as firm as possible. In the end, you will congratulate yourself for not having interfered in this delicate situation at the wrong time.

What to do if the psychotherapeutic treatment does not convince you

If you think that more can be done for your family member's depressive state, or that another therapist (for personality reasons) or another type of treatment might be more suitable, bring your ideas and concerns directly to the doctor. Every

therapist is prepared for such eventualities, and knows that a relationship of trust and confidence (not only with the patient, but also with the family) is of paramount importance for the success of the treatment. Personally, I have no interest in treating a patient if the family do not agree with me, because in such cases, consciously or unconsciously, their attitude would nullify any progress made in psychotherapy. If you have uncertainties, whatever they may be, do not hesitate to bring them up. The therapist can dissolve them with answers as clear as your questions. If you are still not convinced, ask for an appointment with a colleague. Any responsible therapist will be ready to do that.

XIV. TREATMENT: WHO CAN CURE?

When you are faced with depression, one problem above all is the one you initially have to solve: who can treat my family member? Where can I take him or her for treatment?

Trying to solve the first problem, you will discover that besides your family doctor there are other categories of therapists who deal with depressive disorders. I will talk about these in a moment.

When investigating the question of 'where', you will learn that there are many different types of institutions, both outpatient and inpatient. Your doctor will give you concrete guidance.

WHO CAN TREAT DEPRESSION?

There are psychiatrists, psychoanalysts, psychologists, non-medical therapists, and so on, and all of them can claim to be competent in treating depressive disorders.

The psychiatrist

A psychiatrist is a medical doctor, qualified to practice medicine, and specialised in psychiatry, which means that he or she is qualified to diagnose and treat all

types of nervous, emotional and mental disorders. Only a few psychiatrists work using any psychiatric treatment method, but they are the most qualified to diagnose and treat depressive disorders. The approach used is to tailor treatment to the patient's physical and mental condition, rather than forcing the individual case to conform to predetermined treatment modalities. At the same time, the doctor remains flexible enough to be able to refer the patient to any other type of treatment that may be necessary, depending on new facts in the course of the illness.

difficult to make an appointment with a psychiatrist?

Not at all. The best thing, of course, is to consult your family doctor, who can refer you to a psychiatrist whose address and work methods he already knows, and who can therefore answer in advance any questions you may have about him.

Another channel could be the Medical Association in your province; or you can go to the nearest psychiatric hospital and ask for the name of the head doctor. If he cannot see you, he can recommend a colleague to whom you can turn.

The psychoanalyst

There are two figures of the psychoanalyst. The first is the medical psychoanalyst, who has a degree in medicine, and has followed a course of Freudian or neo-Freudian psychoanalytic training. The psychotherapeutic method to which he or she basically refers is psychoanalysis, and in treating the patient he or she keeps strictly within the psychodynamic principles of the latter. He may prescribe medication or physical therapy, depending on whether he keeps more or less strictly within the limits of the Freudian orientation.

The second figure of the psychoanalyst is the non-medical psychoanalyst. He has a degree in psychology (or, in another discipline), or he may not have a degree; however, he has followed a regular course of psychoanalytic training according to the criteria of the school to which he belongs.

The psychologist

A psychologist is a professional with a university degree or a postgraduate diploma in psychology. Their curriculum includes the study of the fundamental theories of psychological functions and their correlations with behaviour. Some psychologists have specialised in the study of tests, i.e. the psychodiagnostic study of the personality and psychological state of the person. Others devote themselves to research, or put their talents at the service of social problems, or work in industry.

There is also the figure of the clinical psychologist, who is dedicated to individual or group psychotherapy. However, as far as your depressed family member is concerned, it is good to know that a psychologist is generally not authorised to diagnose and treat mental disorders, nor to prescribe medication, carry out physical treatments or use any procedures that are specifically the responsibility of a doctor. Many clinical psychologists are able to provide effective psychotherapeutic treatment of depressive illnesses if they are not particularly severe, and always working under the supervision of a psychiatrist or within a hospital or clinic.

Non-medical therapists

The non-medical therapist is also not authorised to prescribe medication or carry

out treatments that are the responsibility of a doctor. The therapist in this case may be a priest, a social worker, a ed nurse, and anyone who operates using the tools of psychoanalysis, psychotherapy and counselling (so-called 'ive therapies'). In employing these techniques, such therapists often go beyond the limits of their actual competence, making diagnoses and prescribing and practising particular psychotherapeutic treatments. Many, however, provide their services in clinics and hospitals.

CONCLUSION

Looking back at many of my patients, I can attribute much of the credit for their recovery to the participation of family in the healing process. And it was the many meetings with many families, the questions I was asked and the answers I gave, that provided me with the material for this book. I am also convinced that this information may have revealed to you the mysteries of depression.

In the course of this paper I have aimed at one fundamental goal - to set out facts that will enable you to cope with and understand your family member's condition, wherever he or she is treated, during and after treatment, and even before seeking medical advice.

Therapeutic treatment can do a great deal for the depressed person, but you yourself, as I have said repeatedly, have a role to play which often proves decisive. If this book succeeds in breaking down the wall of 'hearsay' surrounding depression, and in relieving the family of the anguish into which it is thrown when one of its suffers from this illness; if it can help to bring the depressed person back to a normal life, it will have achieved its aim.