STEP forum speakers included (from l) Dr. Darrel Regier, former county executive Doug Duncan, Dr. Helen Mayberg, Dr. Maurizio Fava, Dr. Jeanne Miranda and Dr. David Shaffer.

“It’s a wonderful example of what honesty when dealing with a health issue can do for a community,” said Dr. Darrel Regier, executive director of the American Psychiatric Institute for Research and Education and moderator of the STEP forum.

Before handing the floor to Duncan, Regier provided an overview of the characteristics and prevalence of depression. It affected 10 million adults in the U.S. in 2006 and 2 million children and adolescents ages 10-17. Major depressive disorder creates $37 billion in annual workplace costs in the S. and increases both worker absenteeism and presenteeism, or when a worker is present but not productive. It can exacerbate other physical illnesses, greatly affect relationships and social life and, at its worst, lead to suicide.

Dr. Darrel Regier, executive director of the American Psychiatric Institute for Research and Education, moderates the STEP forum.

He explained that for the diagnosis of a major depressive episode, 5 out of 9 symptoms are required. These include a depressed mood, decreased interest in pleasure or activities, change in appetite or weight, change in sleep, fatigue or loss of energy, physical slowness or agitation, feelings of worthlessness or guilt, a decreased ability to think or concentrate and thoughts of death and suicide. He discussed the differences between major depressive and bipolar disorders, the role family history plays in the condition and the causes of depression that seem to be a combination of genetic vulnerability and environmental stressors. Only 51 percent of people with depressive disorders get treatment in any given year, Regier said.

Duncan drove all these points home. He has a family history of depression: his grandfather and father struggled with it, and he’s one of 13 siblings, many of whom have shown signs of depression at varying levels. But at close to 50 years old and seeing no signs in himself, Duncan had believed he didn’t have “the family curse.” When, a few years ago, he started having “feelings of worthlessness” and found himself dreading having to go to a public event, he thought it was just “the normal stress of the job.” But the feeling worsened as he began his campaign for governor. “I had 9 of the 9 symptoms,” Duncan said, referring to Regier’s list. “[The depression] hurt physically.” He described the pain as a “pit in the stomach that won’t go away.”

When it finally hit him that he must be suffering from depression, he immediately saw a psychiatrist who diagnosed him with major depressive disorder. And though he started treatment right away, he realized he could not run for governor. “I decided, I can win this thing if I’m myself, but I’m not myself,” he said. When he announced in June the reason for dropping out of the race, he received an outpouring of support. People said he was courageous for announcing it this way, he said. “But, to me, what took courage was to admit that I couldn’t do this on my own.”

“I decided, I can win this thing if I’m myself, but I’m not myself.” —Doug Duncan, on dropping out of the Maryland governor’s race after being diagnosed with depression

It took Duncan about 5 months, he said, to feel like himself again. And now he’s making a concerted effort to talk about his experience with depression and “try to de-stigmatize it.”

This need for educating the public on depression was echoed by all the forum speakers. Dr. Jeanne Miranda, a professor in the department of psychiatry and biobehavioral sciences at the University of California, Los Angeles, discussed disparities in depression care in this country. She said that if it was difficult for Duncan to face the condition, “imagine what it’s like for minority and low-income women.” She explained that mental disorders are more common among the poor and while they are not more common in minorities than in other populations, symptoms of mental disorders are. Furthermore, minorities are less likely to get mental health care and to receive appropriate mental health care when they seek it.

However, Miranda said, some studies offer hope. She described her work on a randomized controlled trial of 267 women screened in county clinics. Though the trial required a lot of outreach and effort to get the women in to receive treatment, she said the response to the interventions was very positive. From her research, Miranda said, it’s clear that it’s very important to develop community interventions that would bring more support for helping individuals who are depressed get mental health care.

Dr. David Shaffer, a professor and chief, division of child and adolescent psychiatry, College of Physicians and Surgeons at Columbia University, discussed another group for whom depression needs further community outreach: children and teens. He looked at recent trends in teens feeling sad or hopeless and discussed the psychopathology for teen depression as well as treatment options and response. He gave an overview of research on suicide in adolescents and examined the question of the effect of selective serotonin reuptake inhibitors on the age group.

Dr. Maurizio Fava, associate chief of psychiatry for clinical research and director, Depression Clinical and Research Program, Massachusetts General Hospital, provided an overview of treatment options for depression. He reviewed the way antidepressants work and discussed pharmacotherapy with naturally occurring compounds like the “wildly popular” St. John’s wort as well as electroconvulsive and other neurotherapeutic treatments. Fava is co-principal investigator of the STAR*D Treatment Trial and he outlined some of its findings. It showed that in a patient’s first and second attempts at treatment, “the chances of remitting…are greater than 50 percent,” Fava said. However, if the patient tries a third or fourth method of treatment, the chance of remission is reduced.

As concluding speaker, Dr. Helen Mayberg, a professor in the departments of psychiatry and neurology at Emory University School of Medicine, discussed the role of brain imaging in the development of new treatments for depression. She said the feeling Duncan described—of simultaneously suffering an active anguish with a mental “numbness”—offers “a clue that parts of the brain may be working in concert, but doing very contradictory things.” Mayberg has tried to determine the circuitry of depression by looking at the parts of the brain that change when a person goes from a neutral to sad mood. A part you see “turning up,” she said, is called area 25, and as it gets more active, the frontal cortex “turns off.” In a deep-brain stimulation study of six chronically depressed patients, Mayberg and her colleagues determined to try to “turn area 25 down” by placing electrodes in the brain in a surgical procedure. The patients related a resulting feeling of “intense calm” and said it felt as if the pain, the “pit in the stomach” Duncan described, had been removed. All six patients are in remission, and though they do have ups and downs, they now handle stress differently. “It’s clear this is not a mood elevator, this is removing a negative,” Mayberg said.

It was further evidence that clinical depression is different than being sad, that additional research into causes and treatment are vital and that the more the illness is brought to light by researchers— and by public figures like Duncan—the more often depression can be overcome.