Charles Meusburger, MD......................................32

conflict/s, unexpressed anger/rage, pernicious guilt and or shame, fear of many things such as mortality, security, health, financials, more trauma, bullying, undesirable exposure(s)/judgments by others, failure or even at times, success, lack of purpose/”failure to launch” at any age, loneliness, isolation, boredom, personality disorders, environmental matters such as war, pestilence, COVID, climate, political upheaval, injustice(s), helpless-hopeless states, neurological, organic and genetic factors, just to name a few on the spectrum of so many possibilities. The absence of the so-called softer items can certainly be contributory as well. For example, the absence of general empathy, tolerance, kindness without a hidden agenda, hence decency, acceptance, generosity of spirit and beyond, the decline of a spiritual spirit for those who are fortunate enough to possess this, civility, artful beauty, appreciation of nature and each other, anything refined and fine, values that are consistent and shared, desire to grow and become better, even manners and genuine caring, even for just peace as a goal can negatively add to depressive sources. The symptom complex that routinely presents itself oft times gradually, but progressively, has several common themes. However, like any disorder or any trauma, depression is uniquely and idiosyncratically, experienced by the given individuals just like their thumbprint. The more common symptoms may include: sadness, low energy (anergia), low motivation (amotivational), no pleasure--even in things that used to provide that (anhedonia), no interest (apathy), altered sleep patterns such as excessive or diminished sleep, and altered appetite that may include loss of appetite or binge eating, for example. Other symptoms may include impaired cognition and concentration, enormous guilt, shame or worthlessness, helpless-hopeless states that could lead to suicidal thoughts (ideation) or completion. A constellation of these must be experienced for at least a 2-week period for a diagnosis to be made. The ultimate cost of serious depression is suicide and sometimes, in combination with homicide as well. These are also the ultimate angry acts where control lost is reasserted in the extreme by acts of permanent, fulminant aggression to express rage, the pain, the sadness, the helplessness and the overwhelm. Sometimes freedom is sought via this exiting event – at least a sense of relief or release from the chains that bond them. Such a permanent choice is up to one’s beliefs as to any goals achieved. No one has ever come back or sent me a sign who’s completed this act to tell me ‘it’s fine, I’m good, it worked. Tell any of your patients to feel free to follow through with their impulses or premeditations – “come on in” – the water is fine.” It is quite a major ‘crap shoot’ at the very least with consequences that devastate those left behind as well. However, depression often demands pain relief and at all costs. It never enhances cognition, but rather makes a powerful emotional, psychological, biological and environmental state and pumps it up into hyperbolic, warp strength that most often yields desperation and tragic outcomes if left alone and untreated. Treatments for this prevalent and powerful disease range from psychopharmacology to various talk therapies. Antidepressants are among the most prescribed class of medications in the world—no wonder, though the latest antidepressant to be marketed was Ttintellix in 2013. Nonetheless, approximately 37 million adults in the United States or 13.2% are on antidepressants. Among the more recent psychopharmacological medications are Esketamine (Spravato), intranasal ketamine for treatment of resistant depression was marketed in 2019. Psilocybin or psychedelic medicine has recently received FDA designation as a ‘breakthrough therapy’--but is not fully FDA approved as yet; again, it’s for treatment of resistant depression. Electroconvulsive Therapy (ECT) was FDA approved in 1978 for the treatment of depression. Transcranial Magnetic Stimulation (TMS) was FDA approved for treatment of resistant depression in 2008. Various talk therapies are also included in the armamentarium of interventions available to help fight depression. These therapies include: Cognitive Behavioral, Dialectical Behavioral, Insightoriented, Supportive and Psychoanalytical modalities. Each has its own niche cohort that they can assist; often in conjunction with medications or alternative methods. The annualized financial cost to treat depression and its additional consequences has an estimated $210 billion price tag---that’s billion dollar cost per annum in the United States. Only 40% of this enormous amount is associated with depression itself. Depression very commonly co-occurs with anxiety that creates a dual threat and an even more challenging disorder to remedy. Clearly the numbers are staggering and almost unbelievable. They can be published, but they represent only a portion of the problem as these numbers represent cases, i.e. people in pain. Unfortunately, the numbers of cases unreported are estimated to be likely double what we know. The numbers of patients who actually seek and receive appropriate treatment are in the 20 to 25% range and vary among age groups and racial-ethnic populations. The number of patients who improve to remission (no symptoms) regardless of the treatment(s) applied, but mostly with antidepressants range from 65 to 70%. Hence, treatment helps. An experienced, well trained professional, team, varying degrees of structured care where indicated that may include: Intensive Outpatient (IOP) treatment, or hospitals, all can be beneficial. This disease is any equal opportunity thief—even an assassin that readily afflicts everyone of all ages, sizes and colors; but it can be helped meaningfully.