"My soul -- there's naught can make it less; My soul -- there's naught can mar; Yet here it weeps with loneliness Within its lonely star. My soul -- not any dark can bind, Nor hinder any hand, Yet here it weeps -- long blind, long blind -- And cannot understand." -- From"Little Gray Songs From St. Josephs," by Grace Fallow Norton
There isn't too much left of turn-of-the-century New England poet Grace Norton except her movingly expressed depression.
If she'd had a 1980s psychiatrist, she might be feeling better (and perhaps been unremembered, but that's a different matter).
Dr. Rex Cowdry, specialist in medical depression at the National Institute of Mental Health, finds it "disturbing to go back and read literary descriptions of what depressions were like when we really had no effective treatment for them."
Dr. Cowdry's message is clear: There are effective treatments today for many of the long-lasting depressions that "markedly impair" a person's ability to function, that can focus life into despair so profound, a feeling of worthlessness so pervasive, that an individual may move through life as a despondent zombi -- or just give up, turning to violence against him or herself, and sometimes against others.
Dr. Cowdry and his colleagues call this "Depression With a Big D."
These days, by and large, most people shouldn't have to feel that way.
Nor should the "Big D" be confused with "little 'd' depression," the "depressions that are a part of everyday life -- sadness, the blues, reaction to an event that sets one back, disappointment."
The little depressions are the wounds that time heals.
Those that time doesn't heal, Dr. Cowdry would like to know about.
So much in fact that he and his staff of "2 1/2 psychiatrists, a psychiatric nurse and a psychiatric socialworker" at NIMH are offering free consultations and evaluations to people who are depressed.
Some, if they are willing and fit Dr. Cowdry's planned research, will be offered treatment as well. Others will be diagnosed and counseled, perhaps referred to appropriate treatment centers or programs. (A doctor's referral will be needed for those who participate in the NIMH program.)
"The person," says Cowdry, "who is acutely suicidal and obviously depressed is a major public health and educational problem, because many people who are depressed never seek out any treatment."
Medical depression, the "Big D" kind, has certain classic symptoms, in addition, of course, to feeling depressed. Its triggering causes may differ markedly in men and women, as writer Maggie Scarf has pointed out in her book, "Unfinished Business, Pressure Points in the Lives of Women," but the symptoms are little different.
The pattern, detailed in Scarf's book, is summarized by Dr. Cowdry: "indecisiveness, fuzzy-headedness, sleep distrubances -- too much or too little, and especially early (4 a.m-ish) wakening; appetite disturbances -- eating too much or too little -- are all fairly classical of serious depressions and they're the same in men and women."
Medical depression -- the "Big D" kind -- is, says Cowdry, "best regarded as a medical illness. It can come out of the blue, or because of some major event. But once established, it takes on a life of its own, lasting months to years.
"It is the kind of disorder we regard as a medical illness and really should be treated very actively."
One of the problems, however, is that the symptoms themselves may keep the patient from seeking treatment. "Hopelessness and helplessness," says Cowdry, "are part of it. People feel that they are worthless and perhaps do not deserve to be helped. There is almost a sense that some people feel that it is like a moral illness or an illness of the will. They are actually embarrassed to admit it."
Sometimes, he says, a family member will need to take the initiative. Generally, once the decision is made, the patient is willing to try treatment even if they think it won't help.
Treatment of depression today with certain classes of drugs and psycho-therapy is almost always at least partially and often dramatically effective. Because of depressions -- both those which alternate with 'highs" (bipolar) and recurrent (unipolar) bouts -- respond to drugs, researchers theorize that some biochemical imbalance may be at fault, or at least involved.
Cowdry, Georgetown University psychiatric resident David Gardner, and other NIMH staff members, are eager to pursue lines of research with patients who can be effectively treated by a combination of drugs and psychotherapy, mostly on an outpatient basis. "Study of these so-called typical depressions," says Cowdry, "could be a great help in unraveling the secrets of what is behind derpression."
Researchers already have learned that certain hormones and the recently discovered substances called neurotransmitters are present in greater or lesser degrees in depressed persons. It was found recently, for example, that the neurotransmitter serotonin may be reduced in people who attempt suicide. Regulation of the hormone cortisol, known for its effect on moods, is "markedly abnormal" in depression.
It also has been found that if some depressed persons are deprived of sleep for a night, the depression lifts the next day, only, unfortunately, to return again after a night's sleep. "We don't know," concedes Cowdry, "what that means."
Cowdry and his colleagues plan to examine, treat and study patients -- physiologically and behaviorally, awake and asleep -- with the broad facilities at NIH mobilized for the purpose, including its sleep lab and sophistcated biochemical and neurological equipment. The scientists will "look at shifts in the realtionship between activity, temperature, sleep patterns and patterns of hormones in a person who is living life in a depressed state."
"One of the striking things," Cowdry says, "about the way the human body is organized is that there is an extraordinary 24-symphony with different hormones coming in on cue at different times. It is a truly extraordinary -- at first glance chaotic -- but at second glance well-organized system that keeps us functioning. But it is studying exactly how that orchestration changes in different mood states and in response to treatment, that is particularly intriguing to us."
Cowdry feels the project may help distinguish which patients will respond best to which medications, pave the way for new, more effective agents with fewer side effects and lead to a clearer understanding of the infinitely complicated sets of systems that make us human.
Those interested in evaluation or participation should call (301) 496-4037. (No area code needed in the Washington Metro area.) Or write: Dr. Rex Cowdry, National Institute of Mental Health, Building 10, Room 4S239, 9000 Rockville Pike, Bethesda, Md. 20205.