In the treatment of children and adolescents with eating disorders, depression is a not uncommon finding. Sometimes we identify it on admission to Kartini Clinic, sometimes it has already been identified before the patient ever saw us, and sometimes it is a residual of otherwise successful treatment. The latter is especially frustrating.

There is a saying in medicine, “when you leave the appointment feeling depressed, you know the patient's diagnosis.” Which might be why many practitioners dread treating patients who are suffering from depression, especially depression of long standing, and why they resort to “protestant ethic style” interventions largely comprising exhortations to “buck up,” “appreciate what you have,” “throw yourself into your work,” “think of others less fortunate than you,” and -- most prominently recently -- “exercise more.”  

It’s your fault, don't you see? Your sloth and negative attitude have caused this.

Depression is a serious condition, described by physicians since the dawn of medical writing and, before that, known to traditional healers. It has occurred across all times and all cultures and all genders.

I am currently reading a very interesting book, called Depression: Advancing the Treatment Paradigm by Robert Hedaya, MD and Sheila Quinn, both integrative medicine writers and teachers, as well as practitioners.

Certainly advancing the treatment paradigm is important for our patients, and all patients, and an improved understanding of the condition once referred to as “Melancholia” would alleviate the suffering of-- literally-- millions. An understanding of the connections and correlations with other medical conditions, including metabolic disorders of interest such as obesity, would be a great leap forward (remember, though: correlation does not imply causation!).

I may be quoting extensively from this book in future blogs, but today I want to quote the  “Case of Job,” which impressed me greatly. This case references the Book of Job, from that most enduring of written works, the Bible. It is probably one of the oldest books therein, as befits a tale of human misery known even to the ancients. I knew this story from my childhood, but had not really thought of it as it relates to depression. Dr. Hedaya’s summary titles are in bold, the actual quote from the Book of Job (New International Version) are in normal text. Points #9 and #10 especially were arrows to my heart.

Job was a pious and wealthy Hebrew who lost his entire fortune, endured many horrible diseases and whose children were all killed in a short space of time. I think this qualifies as an adverse environment!  

If you read the Book of Job, the details of his afflictions are excruciating. But to stick with those that reflect a timeless description of human depression:

  1. Passive suicidal ideation-- “Why did I not perish at birth, and die as I came from the womb? I despise my life; I would not live forever."
  2. Anxiety/obsessiveness--  “I have no peace, no quietness: I have no rest, but only turmoil. When I think about this, I am terrified. Trembling seizes my body.”
  3. Hopelessness--  “What strength do I have, that I should still hope? What prospects, that I should be patient?”
  4. Insomnia--  "When I lie down I think, ‘How long before I get up?’ The night drags on, and I toss until dawn.”
  5. Infection/inflammation/malnutrition, poor self care--  “My body is clothed with worms and scabs, my skin is broken and festering. My breath is offensive to my wife.”
  6. Social withdrawal/loss of meaning--  “Let me alone; my days have no meaning.”
  7. Anhedonia--  “My days are swifter than a runner; they fly away without a glimpse of joy.”
  8. Social ostracism-- “I am loathsome to my own brothers. Even the little boys scorn me; when I appear, they ridicule me. All my intimate friends detest me; those I love have turned against me.”
  9. Failure of treatment--  “...you are worthless physicians, all of you! ...your maxims are proverbs of ashes; your defences are defences of clay… I have heard many things like these; miserable comforters are you all!  Will your long-winded speeches never end? What ails you that you keep on arguing? ...So how can you console me with your nonsense?  Nothing is left of your answers but falsehood!”
  10. Reduced appetite/weight loss--  “I am nothing but skin and bones.”