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1997 January/February (2)

Friday, 02 January 2009 10:41

Stronger Medicine

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Stronger Medicine

Anti-Depressants Haven't Made Therapy Obsolete

by Michael Yapko

IT WAS MID-MORNING ON THE FIRST DAY OF THE LARGE Psychotherapy conference when I first began noticing the small white buttons with their pithy little saying sprouting on the lapels of conference attendees: "DEPRESSION: IT'S AN ILLNESS, NOT A WEAKNESS." By late afternoon, the buttons, dispensed at an exhibit booth for a large pharmaceutical company, were everywhere. I glimpsed them affixed to collars, pockets, belt loops, purses, backpacks, folders, any spare inch of apparel or appurtenance. It was startling to see how quickly a slogan could capture the allegiance of so many of my colleagues, especially when so many of them shared a common preference for brief, solution-oriented psychotherapies. Why were they so willing to make a public endorsement of the saying? For one thing, the slogan is catchy. It seems to suggest that we've moved beyond an era of superstitious belief and finally uncovered depression's "true" nature. The idea that depression is a clear-cut illness, caused by a "chemical imbalance" that can be cleared up with a daily dose of Prozac or Zoloft, now threatens to become a widely accepted clinical mantra and a popular shibboleth, repeated in best-selling books, mass-circulation periodicals and morning TV talk shows.

Currently, the most common mental health disorder in America and one of the most costly depression racks up a staggering $54 billion a year in costs from work absenteeism, reduced productivity, lost earnings and treatment expenses, according to a 1995 study by the National Institute of Mental Health. Depression is also among the most medicalized of psychiatric diagnoses; indeed, family doctors, not psychiatrists, write up to 70 percent of antidepressant prescriptions, with a wide array of meds to choose from. With the lion's share of mental health research dollars going into psychopharmacology during the past 15 years, there are now five major classes of antidepressants on the market. Seven new medications have been introduced within the last 10 years alone, and about 15 more are now being tested by the pharmaceutical companies.

But does the wide prevalence of depression, the staggering popularity of drugs to treat it and the obvious zeal for medicalizing the whole problem constitute prima facie proof that it is a disease? Can we now reduce the complex phenomena of depression, with all its emotional, cognitive, relational, social and biological elements, to a simple neuro-chemical mistake? Or is it possible that most depressed people are not "sick," and that biology only represents one component in the reasons for their depression and the way they experience it?

While thesymptoms of depression, at least as officially described in the Diagnostic and Statistical Manual, may seem to many to be fairly clear-cut and predictable, its origins and antecedents are not. Genetics, childhood trauma, unconscious guilt, neurochemical imbalance, poor interpersonal skills, learned helplessness are all potential "ground zeroes" by one school of therapy or another. In fact, the way therapists regard and treat depression might be considered as a kind of professional Rorschach test, revealing far more about their theoretical allegiance than about the true condition of their depressed clients. Analysts are trained to think of depression as the consequence of unresolved childhood developmental losses; cognitive therapists look for errors in thinking and belief that reinforce negative emotions; behaviorists help clients extinguish habits that contribute to depression; and family therapists study systemic or interpersonal triggers for depressive symptoms. However different the methods and the philosophies of their proponents, all these models provide valuable insights into the hydra-headed entity of depression, and none can stand as the final, defining word. But of all of the methods for treating depressed clients, biological psychiatry is today in the ascendancy, due largely to the proliferation during the last 15 years of effective medications for treating depressive symptoms with fewer side effects than ever before.


The rising fascination with evolutionary psychology and biological determination has led some experts to proclaim, without much evidence, that all emotional states (including depression) are ultimately based on biology.

One study published in Psychological Science in 1990 by Robert Plomin, Robin Corley, John DeFries and David Fulker, for example, suggests that one's amount of television viewing may be genetically determined. A 1992 study in the same journal by Matt McGue and David Lykken indicates that the tendency to divorce is also biologically determined. Do we really have genes for TV and divorce? Where and how in human history would we have acquired such genes (that only seem to have been activated in the last 30 or so years)? Indeed, as psychologist Stanton Peele writes in Diseasing of America, it is currently fashionable to view all kinds of self-defeating personal behaviors, including eating disorders, excessive shopping and too much sex, as evidence of disease.

The push to redefine depression as a disease is aided and abetted by the managed care industry, which encourages the use of antidepressant medication as a treatment approach. According to psychiatrist Matthew Dumont, "It seems that if we so much as inquire whether a depression might be related to the stresses or losses of life before blasting it with a chemical, we are virtually guilty of malpractice."

But this devaluation of therapy that inevitably accompanies the new emphasis on biological approaches is wrong-headed on two fronts. In the first place, epidemiological, social and cultural data indicate that, for most people, depression is not a disease of biological origin. Increasing in prevalence among all age groups, it is growing most rapidly among late adolescents and young adults. The average age of onset for a first major depressive episode has been steadily decreasing and is now the mid-twenties. Since gene pools and biochemistry do not tend to change so markedly in so short a time, the evidence supports an argument for social and cultural causes for depression in most cases. Since 1945, when the first of the baby boomers, who suffer dis-proportionately from depression, were born, our cultural mores have changed profoundly. The breakup of the family, explosive technological growth, dwindling resources, violence, terrorism and the threat of nuclear disaster have undermined our sense of social stability and cast deep shadows over future expectations. Writing in the Archives of General Psychiatry in July 1985, psychiatrist Gerald Klerman and his colleagues identified some of the social stresses they believe account for the higher rates of depression. These include urbanization, changes in family structure, new gender roles and occupational shifts. All of these trends unsettle people, uproot them from traditional mores and meanings, confuse them about who they are and what is expected of them and create many new opportunities for experiencing inadequacy and failure. Psychology researcher Martin Seligman suggests that, as a people, we tend to be more self-absorbed than our forebears, and thus more hypersensitive to each transient mood. Seligman thinks that we may also have unrealistically high expectations of ourselves and others, even as we increasingly feel both more helpless and hopeless about controlling our lives.


This dichotomy is even more confounding for our own emotional well-being, Rates of depression and symptomatology vary widely from culture to culture and between genders, also lending support to the theory that the interplay of social, cultural and psychological factors is generally more important than biology. The Amish, for example, have considerably lower rates of depression than do other Americans. Their lower incidence of depression presumably relates to cultural factors, including vital religious beliefs, close-knit community ties and a reliance on their own labor rather than technology. Women in this country are two or three times more likely to be diagnosed as depressed than men, in part for biological reasons (reproductive events like postpartum depression and possibly premenstrual syndrome), but more likely because of systemic social inequities and cultural conditions.

There is no question that genetics and biochemistry play a part in depression, but the best data from identical-and fraternal-twin studies indicate that genetics can be identified as a cause of unipolar depression less than 20 percent of the time. But, if, as the evidence now shows, cultural and social forces contribute more to the onset of depression than does biology, medication is only a partial solution.

More important, there is now abundant evidence that therapy is as effective or more effective than drugs are for treating depression, with lower rates of relapse. In the January 1994 issue of American Psychologist, Ricardo Munoz, Steven Hollon et al. reviewed guidelines for treatment of depression developed by the Agency for Health Care Policy and Research (AHCPR) that compared thousands of treatment outcome studies using drugs alone, psychotherapy alone or a combination. Evaluating the guidelines, the authors concluded that psychotherapy was at least as efficient as drugs for relieving depression. And, on many measures, including treatment-dropout rate, social adjustment, symptomimprovement and relapse rate, psychotherapy performed better than meds. Several metanalyses of many controlled studies involving thousands of patients have reached the same conclusion. One is a recent review by David Antonuccio et al. of numerous studies comparing drugs to therapy and the value of both approaches combined, published in the December 1995 issue of Professional Psychology: Research and Practice, which reports substantial evidence for the superior effectiveness of therapy. There is "no stronger medicine" for depression than psychotherapy, writes Antonuccio in a recent issue of the American Psychologist. So, while medications can help relieve symptoms, and possibly help clients take better advantage of therapy, the reputation of Prozac or Zoloft as miracle cures for depression, rendering therapy obsolete, is simply not supported by research.

Late last year, the position of therapy was buttressed even more by the largest survey ever conducted of people who had undergone outpatient psychotherapy treatment, published in the November 1995 issue of Consumer Reports (See Around the Network, January/February 1996 Networker) and based on extensive reader-response questionnaires submitted by 4,000 subscribers. Unlike standard efficacy studies, with their random assignments of clients meeting rigid eligibility requirements to standardized treatments, the Consumer Reports survey caught the experience of therapy as it really is for most people with therapists who typically offer an eclectic mix of approaches and adjust their work to individual clients.


Of respondents to the survey, 87 percent said they felt better after treatment. There was no significant difference between psychotherapy alone and in combination with medication for any disorder, including depression. And social workers, psychologists and psychiatrists all had roughly the same rates of success. Most surprising, perhaps, to a field giving increased emphasis to brief therapy, respondents reported better results for longer treatment. Among those with similar levels of emotional difficulty, those who stayed in therapy more than six months said they made greater progress than those who left earlier. Not surprisingly, people whose choice of therapist or whose length of treatment was dictated by insurance coverage improved less than those who freely chose the clinician and modality.

Although the Consumer Reports study is not without problems low response rate to the questionnaire, lack of specificity to the depression diagnosis and other possibly distorting factors it broke new ground. By going directly to the mental health consumer, it produced the most naturalistic view of the actual experience of therapy of any study of the field ever conducted. According to psychology researcher Martin Seligman, principal consultant on the survey, writing in the December 1995 American Psychologist, "[The survey] is large-scale; it samples treatment as it is actually delivered in the field; it samples without obvious bias those who seek out treatment; it measures multiple outcomes . . .; it is statistically stringent and finds clinically meaningful results ... Its major advantage over the efficacy method for studying the effectiveness of psychotherapy and medications is that it captures how mid to whom treatment is actually delivered and toward what end. ... It provides a powerful addition to what we know about the effectiveness of psychotherapy and a pioneering way of finding out more."

While medications are often invaluable for symptom relief of depression, their effectiveness is not evidence for an underlying physical pathology. Medications work because they have a relevant chemical effect, indicating a correlation between their impact on specific neurotransmitters and mood. But while there are some cases in which medications may help depression sufferers without additional treatment, the consensus among most depression experts is that only prescribing medications is generally a disservice to the client. Most people require much more substantial psychotherapeutic help to learn the skills necessary for solving problems and avoiding future difficulties, if their medication-improved mood is to endure.

What is it about psychotherapy that makes it so vital to treatment, that gives depressed clients something they cannot obtain from medications? People become and stay depressed partly because they tend to explain life's ordinary defeats and disappointments in terms of their personal inadequacies and failures, and then believe their own negative opinion of themselves. Others have deeply pessimistic worldviews that influence their mood states and tend to engender self-fulfilling prophecies. A healing relationship with a therapist can provide the kind of personal support and teaching that can clear up the misperceptions that contribute to the negativistic view of life typical of depressed people. Therapy can help clients see life events from different perspectives and reattribute experience by assigning alternative explanations for life events that are less damaging to themselves than the typical depressive worldview. The ability to see and interpret events from new perspectives is critical to mental health.


As we become increasingly a nation of wanderers, our lack of steady and sustained social connections and consequent lack of competence in relationship skills provokes even higher rates of depression. Our ethos of extreme individuality and personal rights over collective responsibility and social accommodation increases the likelihood that we will be lonely and depressed, without the deep ties to family and friends that can immunize us against alienation and despair. But there is no disease here, just a way of responding to life that is proving ever more toxic to our individual and collective psyches.

As therapists, what can we do in the face of this rising tide of depression, which deeply implicates not the faulty biology of millions of people but the depressing nature of our civilization? And how can we counter the myth of pharmaceutical omnipotence that undermines our own confidence in therapy and our appreciation for its irreplaceable role? We must be aware that therapy works with depressed people because it draws on the clinical skills and adaptability required to understand a complex disorder skills no pill can mimic. Therapists also need to emphasize active, solution-oriented treatments over pathology-based passive ones. Rather than search the dim past for causes of presumed deficits, we need to actively teach clients the specific skills they need to manage their feelings and develop what author Daniel Goleman calls their "emotional intelligence."

Martin Seligman, in his book, The Optimistic Child, writes that antidepressant skills for interpreting and responding intelligently to life events can be taught at a young age. We can prevent later misery by teaching children to be more flexible in their interactions and empower them to solve problems before they lead to entrenched, self-destructive patterns of behavior. Similarly, Robert Ornstein and Paul Ehrlich, in their book New World, New Mind, argue cogently that learning to think preventively acquiring a refined sense of the relationship between "this" course of action and "that" predictable consequence helps people avoid being sucked under by their own moods and emotional reactions. In short, therapists are badly needed to help people learn the tried-and-true skills that used to be considered the hallmark of adulthood. They include the ability to think ahead, critically consider alternatives, anticipate consequences, recognize when to give precedence to the heart or the head and, perhaps most of all, create and maintain solid and satisfying personal connections to other people.

Just as there is no single cause for depression, which is the personal and idiosyncratic response of individuals to a multitude of biological, psychological and social factors, so there can be no all-purpose panacea, like the simple act of taking a pill, that resolves life's difficulties. The idea that depression is a disease reflects, in part, the benign intention to destigmatize the suffering it causes and, less benevolently, the economic pressures to find a cheaper cure. Americans have a history of valuing quick-fix solutions to difficult problems. But this simplistic approach to depressive disorders underestimates the remarkable human capacity for self-transformation. We have the ability to use imagination and intelligence to change our life circumstances, our attitudes and emotions, even, to some extent, our personalities. It is the privilege of our profession to be able to help troubled people along this path, and though medications may make this journey less arduous, in the long run, therapists are indispensable for getting their clients to this destination.


So, for the sake of your profession and your integrity, watch out for facile explanations of depression and pluck off those buttons that reduce complex issues to catchy slogans. Your clients will thank you, and you'll feel better about your vital role in treatment.

Michael Yapko, Ph.D., is a clinical psychologist and marriage and family therapist in private practice in Solana Beach, California. He conducts workshops nationally and internationally in hypnosis and brief therapy methods, and is the author of the new book Breaking the Patterns of Depression (Doubleday). Address: 462 Stevens Avenue, Suite 309, Solana Beach, CA 92075.

Friday, 02 January 2009 10:41

The Legacy

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The Legacy

Inside a Family Haunted by Depression

by Martha Manning

MY FAMILY IS HAUNTED BY DEPRESSION. MY MOTHER CAN trace it back in her family at least six generations and it's in my father's family, too. When it hits, it hits hard. We don't get "down in the dumps," we get lost in the pits. Some people find themselves or are found, others get lost forever. The melancholies, nerves and breakdowns of my ancestors landed them in sanitariums, rest homes or in upstairs rooms from which they never emerged. Treatment involved the state-of-the-art interventions of the time cold packs, electric current, sedating drugs. Sometimes people got better. Sometimes they didn't.

Six months into my own treatment for an episode of depression that scared me in its speed, severity and stubbornness, I had placed most of my emotional cards on the table, but was disappointed that my therapist still hadn't constructed some brilliant framework in which my difficulties and those of my family could be finally uncovered and our dysfunction excised. Since he never volunteered his opinion on the subject, I finally just demanded, "Why are there so many problems in my family?" He shrugged and replied calmly, "Because there are so many people in it."

My first reaction was, "I'm paying $100 an hour for this?" And yet, eight years later, his comment still stands firm among my list of top 10 therapeutic interventions of all time. The poet Mary Karr, author of the celebrated Liars' Club, a memoir of a colorful and tremendously chaotic family, recently echoed my therapist's comment when she wrote that her definition of a dysfunctional family is "a family with more than one person in it."

My therapist's comment looks naive sandwiched between some of the more elaborate observations other therapists and clinical supervisors have made to me over the years. But in addition to comforting me with its common sense about the variety of ways families suffer, his words have been an insistent caution whenever I am seduced too quickly into facile interpretations of psychopathology. There is, after all, a very thin line between theoretical elegance and bullshit. These days, the easier the explanation of something as complicated as the relationship between families and depression, the less I trust it.

For every connection we find between our favorite theories and what we see in our consulting rooms, there are probably a hundred such families whose members somehow muddle through in defiance of our ideas about how dysfunctional they and their families are. Understanding the legacy of depression in a family requires more than genetic mapping, family diagrams, or symptom checklists. Each of us is the product of a complex weaving of genes and expectations, biochemistry and family myths, and the configuration of our family's strengths, as well as its vulnerabilities. To truly appreciate the complexity of the weave, we have to sort out the contributions of individual threads to the overall design. Yet, in describing a weaving it would be ridiculous to say, "Well, there's a red thread and over there is a blue thread and here's a gold thread." While these separate observations yield pieces of information, they provide no overall view of the fabric. It is only when we see how red threads braided with blue threads influence the pattern in particular ways that we can even begin to grasp the design of the whole.

MY OWN MEMORY OF BEING haunted by depression extends back to my great-grandmother who lived into her nineties and died when I was about 10. As I began to put things together about the relationship between my grandmother and her mother, I started to wonder whether the dulling of self I sometimes experienced, and its power to contaminate energy and joy, played leap frog with the generations hopping over my great-grandmother and landing on my grandmother, leaping over my mother and crashing down on me.

My great-grandmother was either authoritative or controlling, depending on how negatively her behavior was affecting you at the time. When we made our annual family visit to my grandmother in Massachusetts, we knew our visit would include a pilgrimage to her mother, Grammy Hale. As young as 6 or 7, I knew that there was a whole lot more going on during those visits than I could grasp. My intuitions were confirmed whenever children were dismissed immediately following raised voices. I sensed something big happened during those dismissals. Something bad. Later I found out that these were the times my great-grandmother roundly castigated my grandmother. It didn't matter for what. It could have been my grandmother's break away from a middle-class Irish Catholic neighborhood after her marriage to reside in a big house on the Waspiest street in the town. Or it could have been the tone of a brief comment my grandmother had made weeks before. The crime didn't matter. The punishment was always the same: my great-grandmother's total and complete disgust.

After each visit, as we drove back from Salem, I noticed the way my grandmother deflated, remaining silent on the way back to her house. She was almost impossible to distract from her brooding, even with our most entertaining attempts. Even when we arrived back to her wonderful beach house and celebrated our freedom from creaking musty homes and strange old women, my grandmother was elusive. She stayed in her room, shades drawn against the sun and the ocean, windows shut tight against the clean salt air. It frustrated me to think that she was making herself oblivious to the most obvious ways to feel better.

When we kids asked what was wrong with Grandmother, grown-ups always told us the same things. Grandmother was "tired," Grandmother "needed some rest," Grandmother "wasn't well." And we were told that the only thing we could possibly do to make her feel better was nearly impossible: "Be quiet." Trays that were delivered to her room earlier in the day were retrieved untouched. She didn't even want to see me, her "golden girl" who could usually snap her out of anything. Sometimes, I'd sneak into her room and lie next to her when she was sleeping, matching my breathing to hers and stroking her hair and face. She didn't have a fever, she wasn't throwing up and I didn't see spots anywhere so she wasn't sick in any way I knew about. I wondered if sadness grew with age and actually made people sick. The reasons each siege of sadness finally ended were no clearer to me than the reasons it began. When I asked about these things, unlike other times when I knew information was intentionally withheld, I almost believed my mother when her smile flickered for a moment and she said she didn't know.

On her good days my grandmother was magic extravagant, energetic and always interested. She allowed my cousins and me to tag along with her on her many errands and activities. She let us know that we were all perfectly wonderful children, despite our parents' petty complaints about us. She was fun in a way my mother never was. But as I grew older, I learned about the other side. On her bad days, I could see my grandmother wilt before my eyes. There was nowhere to tag along, because she didn't go anywhere. She never got fully dressed and when she did, it wasn't worth it. She didn't laugh. She didn't think I was perfect anymore. The air felt heavy around her, very still and hard to breathe. My grandfather, a C.P.A., seemed always to be working. My grandmother went to bed early (many times before dark). For a woman who spent as much time in bed as she did, I was always puzzled by her daily complaint that she didn't get any sleep. My grandfather recedes in my memory as a major player when my grandmother was nursing her depressions and sulks. It's like he just disappeared at those times.

In early adolescence, my relationship with my grandmother changed. Now I felt some unspoken expectation that with my new maturity, I owed her something. Now she wanted me to listen to her complaints of how badly she slept or how my grandfather worked too much or how her children didn't understand her. I couldn't stand her laments. And, since I couldn't do anything about her complaints, I left each interaction frustrated and resentful. She scared me in a way I couldn't and didn't want to understand. I felt an uneasy resonance with her, a sonar that picked up on cues that predicted a shift in her mood.

My mother was not magic. She was practical, rational and smart. As a little kid, I knew that and I loved her for it, because to me it meant that she would always take care of me, that no matter what happened, she was a constant. As our personalities diverged, she seemed more formidable. My mother was in control of her feelings. Mine spilled out all over the place. To my mother, the fact that every day was a new day was a good thing. I was never so sure. I also learned that my own dark moods were best kept to myself. As the oldest of six, I, like my mother before me, was praised for being so responsible, so capable at such an early age. I loved the praise, but I hated the reasons for it.

My mother had a no-nonsense approach to unhappiness. Stay busy, think of someone worse off than yourself, offer it up for the souls in Purgatory. At the pediatrician's office when two or three of us lined up with our bare asses vulnerable to imminent medical intervention, one of us invariably burst into loud and contagious tears, protests and screams. I remember more than once my mother leaning over and whispering, "If you must cry, cry quietly."

I recall her curiosity and impatience at my unremitting despair following being dumped by a boy when I was 13. She was sympathetic to the pain of such an experience and allowed that there was nothing like a good, cleansing cry. It was the intensity and duration of it that proved problematic. My mother had about 15 minutes in mind, whereas I was planning to make a weekend out of it.

Early on, I considered myself flawed in a way that she wasn't. Unlike my mother, I had difficulty with what she calls "compartmentalizing." She could quickly extricate herself from awful feelings; I became mired in them. By my mid to late teens, I began to struggle with the variability of my moods, something that the steamroller approach to life I had learned from my mother could not control. I wondered which woman, my mother or my grandmother, was the preview of my future. My unspoken fear that increased with age was that I was destined to become my grandmother.

I UNDERSTOOD MORE ABOUT THE nature of my mother's strength when I saw her in the context of my grandmother's vulnerability. As I grew old enough to realize that my mother and I could experience diametrically opposed feelings on the same exact subject, I realized she hated visits to my grandmother the very same trips I loved. When I was 6, I looked at the calendar and cried out, "Two more days till vacation." My mother's face got as stormy as it ever gets. She clenched her teeth and spit out, "This is many things, but it is definitely not a vacation.

When my grandmother's mood changed, my mother's did, too. Upon our annual arrival at my grandparents' beach house, it seemed like my grandmother almost willfully fell backward into helplessness and depression. And, in response, my mother went into overdrive. After feeding her own six kids dinner in our adjoining cottage, she rushed up to the main house to feed my grandparents, who somehow made it through the other 50 weeks of the year just fine.

But cooking was the least of my mother's duties. She was my grandmother's personal cheerleader, her therapist, the person who got her up and going, who tried to shift my grandmother's automatic negative outlook at least to neutral. One of my most common memories of those visits is the way my mother and grandmother sat around the kitchen table. My mother always looked like she was sitting on tacks and my grandmother always looked like  she was sinking in mud. The sheer exhaustion she conveyed in the act of stirring her tea made it look like she was mixing cement.

Their conversations always stopped short when I walked in the room, but my mother didn't look at all like she looked in the many kitchen-table conversations she shared with her friends. When I became a therapist, I realized that during those times my grandmother and mother were "in session." It was only once we were on our way home again that I could see my mother's shoulders relax. She started smiling again and tolerated our loud and stupid car games.

In retrospect, I sec how that pattern repeated itself with my therapist-husband when I was depressed, as we sat on the bed or at the table and he tried to get me to articulate what was wrong. Anyone who has ever been seriously depressed knows that that task is as daunting as asking a lame man to tap dance. In addition, it leads to mutual frustration, anger and, ultimately, helplessness. It was only when we both gave up the expectation that my husband could somehow "cure" me that we moved from pseudo therapy to true support. Instead of reaching out with well-intentioned "therapeutic" interventions, he shifted to questions like, "What would help right now?" My therapist was always willing to include Brian in our sessions and, even though they were not present, to recognize Brian and my daughter, Keara, not only as my support system but as people who were suffering also. This freed them from the responsibility of those awful sessions at the kitchen table, where the certainty is that if you stay with this depressed person for one minute longer, you will drown as well.

My grandmother constantly sighed, something my mother never did. It was not an "Oh well" kind of sigh or a "That's life" kind of sigh. Hers was an exhalation that sounded like it could possibly end in her demise. It was a sigh of surrender. But as I got older, I understood that it wasn't pure fatigue or sorrow or hopelessness. It was, in its essence, an angry sigh. It was a challenge: "Just you try and make me feel better. I dare you."

In my twenties, my mother began to tell me about her childhood. She recalled being very happy until she was a teenager. My grandmother was dynamic an energetic cleaner and planner. She loved children and was always wonderful with them. But in early adolescence, something changed. My mother began to return from school to a sink full of dirty dishes, her mother in bed for no obvious reason and no dinner planned. "My memory of ninth grade," she told me "is of gritting my teeth and thinking, 'Oh God, now I have that mess to face.'" But my mother did more than face it. She took care of it.

The expectation that she do it and keep on doing it was never articulated. It was assumed and rewarded with abundant praise, which totally hooked my mother in very short order.

As children, we believed all of my grandmother's promises that things would be better "if only" "If only you lived closer, I'd be happier." "If only your aunt was easier to deal with." "If only your grandfather didn't work so hard." When I was 10, my mother (who rarely said bad things about people) insinuated that we shouldn't count on those extravagant promises our grandmother had made. When we leapt to our poor grandmother's defense, my mother responded, "This is the truth. It's what goes on. I'm giving you the truth. I never got that from my mother. But you will always have it from me."

When I had my own child at the age of 25, my mother became much more open in expressing her frustration with my grandmother for not changing and with herself for not being able to make her. In my late twenties and thirties, the depressive fog that had shadowed me for a long time grew more difficult to override or outrun.

I MOVED TO BOSTON WITH MY husband and daughter to do a postdoctoral fellowship at McLean Hospital. We found a house several miles away from my grandmother, to her great delight. I was thoroughly unhappy with the fellowship, McLean and the move, especially as I realized why my mother had consciously put 500 miles between her mother and herself. It was so sad to see my grandmother's magic destroyed by something so insidious and powerful, that neither my love nor my training could change it. I knew she was in her own hell, yet there were times I wanted to coax her or kick her out of it, dismiss her complaints and sighs, but I couldn't. And I feared I was looking at my future. I didn't want anyone to feel that way about me.

My first cousin the firstborn in her family of seven was going through her own hell at the time from depression, a hell that culminated in suicide in her early twenties. My own deepening depression and my cousin's suicide catapulted me into psychotherapy with a psychiatrist referred by my health plan. I told him I was anxious. He told me I was depressed. Yeah, I admitted, I had my moods, but no way was I depressed in the way my cousin or grandmother was. As evidence against his diagnosis, I listed my accomplishments, the many responsibilities I fulfilled. But 30 minutes into my session with him I was convinced that I was indeed depressed. At the end of our first session, he turned to me solemnly and said, "You really believe that life is something to be endured, to be overcome." I looked back at him suspiciously, wondering if it was a trick question. "It isn't?" I asked. He told me we had our work cut out for us and scheduled a session for the next week.

Our work in the five months that remained in my fellowship was fairly structured and involved learning ways to manage my anxiety and set limits in the many areas in which I felt overwhelmed. Perhaps the most significant result of the work was that I decided not to accept a job at my fellowship and remain in the Boston area, but to return to Washington to accept an academic position there.

Not long after we moved back, I began to hear my grandmother's sighs in my own labored breathing. I, too, felt the weight of the spoon as I stirred my tea. I knew that making a peanut butter and jelly sandwich should be far less than a 30-minute operation. I entered individual psychotherapy, found it extremely helpful, particularly in quieting the loud voice of perfection that used to rule my expectations of myself, and the panic that had begun to sneak up from behind and immobilize me.

But my depression continued despite insight, despite a good marriage, despite a child I dearly loved. I finally agreed to try antidepressants and was horrified when my psychiatrist recommended imipramine, the same medicine my grandmother had used in her late seventies, with moderate success, but difficult side effects. My psychiatrist must have registered the horror on my face. He reassured me that he always chooses as the first antidepressant a drug that has worked with other family members.

He was right. The medicine helped quickly and dramatically. It lifted a lifelong weight off my back and made me wonder, "Is this how regular people feel?" But like many people who take psychotropic medications for significant periods of time, I struggled with questions like, "Why can't I do this on my own?" or, looking at the tiny pills, I wondered, "Is this all that stands between hell and me?"

Fortunately my psychiatrist and I already had a strong therapeutic relationship. Yet despite the benefits of the antidepressant, I still feared that I was destined to be my grandmother, a fear no drug could erase. I didn't want her resignation, her helplessness, her just-be-low-the-surface bubbling anger or her genuine and horrible suffering. I also didn't want to have the impact that she had on her family, particularly on my mother. I did not want my daughter to take on the yoke of responsibility and resent me for it. I had already watched three generational scenarios: My great-grandmother's influence on my grandmother, both of their influences on my mother and all three of their influences on me. The one that scared me most was the next one the weight of all four of us on my 11-year-old daughter.

In addition to support, the therapy focused on developing an understanding of the commonalities I shared with each woman, appreciating aspects of our shared legacies as some of the things I most valued in myself. I also had to articulate the differences between myself and each of them. I worked to understand that depression did not negate me, it just made my life different and difficult hopefully, for a limited amount of time, and that no one genetically, biologically or psychologically is the blueprint for anyone else. Being haunted is not the same as being cursed.

The fact that in little more than a year's time, I descended into a very serious depression does not negate the impact of the psychotherapy or the medicine. For reasons that were never clear, I began to metabolize my medications so rapidly that to keep a therapeutic dose in my blood, I required doses that became untenable. The benefits of each new medicine bottomed out within a matter of weeks.

My daughter tried to tease me, tempt me, annoy me, entertain me and soothe me all to no avail. Her constant question was, "Why are you so sad?" No wonder that I worried about the impact of my depression on her. The self-absorption caused by the acute pain of a severe depression makes being a good parent very difficult. I had difficulty following the rambling conversations in the car that I usually loved. Her new friends' names were hard to remember. Our 11-year-old bedtime ritual, with its whispers, soft songs and backrubs dwindled down to a quick goodnight.

She and my husband hovered and worried. In reaction to my early experience of whispered adult conversations, my husband and I tried to be straightforward with Keara. I remembered what my mother had wished for in her adolescence "Just some knowledge. What's going on and what's being done to help it."

Now, five years since my last serious depression, my daughter teases us that we went a bit overboard in providing the information my mother had wanted. She insists that the information we gave her about depression was a lot like the information we gave her about sex a lot of big words with little context. Her concerns had less to do with having a technical command of depression than about the continuity of her care and protection. Two years ago, at the age of 16, she spoke to an interviewer who was writing a story about my depression: "The thing about having someone close to you suffer from depression is that your feelings go from worried, to angrily impatient, to guilty. One of the worst things was seeing my mom in so much pain and being constantly reminded that it wasn't my fault and there was nothing I could do to make her feel better."

We tried to keep her life as stable as possible. Given my mother's experience, 1 definitely did not want my daughter to "rise to the occasion." In the interview, Keara said: "My mom worked hard to take care of me, to make sure I was taken care of, which I was. I was so lucky to have my father. My parents always shunned the value system where the mother would be the singular child raiser. I was always close to my dad, even closer at the time because I spent more time with him as my mom got worse. Anyway, the shift in my standard of living was not too dramatic."

Despite pills, therapy, love, professional expertise and faith, my symptoms worsened. I didn't sleep more than two hours a night. I stopped eating it was too hard to swallow. I thought about the wisecrack about someone who is "out of it": the lights are on, but nobody's home. In depression, the lights are off, but somebody's definitely home. She just can't make it to the door to let you in.

My ruminations turned to comforting thoughts of death. I had always thought of myself as living in a series of concentric circles that connected me to life. My outermost circles included my interests and acquaintances, my work and goals. Then came my friends. Then my parents and siblings. Then my husband and daughter. As the depression worsened, those connections dissolved. They were no longer reasons to stay in the game. Life could go on without me.

In the final days before my hospitalization, I was staying alive for my husband and my daughter. I never told them this. In the last clays, I kept going only for my daughter. My daughter and her songs. Every morning, Keara stumbles semi-conscious into the bathroom and turns on the shower. Within the space of 30 seconds, she starts to sing. She starts out humming so softly that her voice blends with the spray as it bounces off the wall. And then she chooses her song sometimes sweet and lyrical, sometimes loud and rocking. Each morning, when I had to face another day on two hours of sleep and no hope, I leaned against the bathroom door waiting for her to sing and let her voice invite me to try for one more day.

One morning, finally convinced that suicide was an act of love, not hate, I leaned for what I thought would be the last time against the door. I tried to memorize that voice, with all of its exuberance and hope. And then I realized that ending my life would silence that voice, perhaps forever. And I knew what I had to do. I would finally agree to electroconvulsive therapy (ECT), which had been recommended to me for several weeks. I had always said I'd step in front of a moving train for the sake of my child. Now it was time to prove it.

ECT was the tractor that pulled me out of the mud. Its power was hard to believe. Within several treatments, I was adding 20 to 30 minutes to my sleep per night. Having lost 30 pounds in three months, I began to look forward to meals. My face, which felt like a mask, regained its elasticity. It was as if several heavy backpacks had been taken from my shoulders. But it wasn't a magic cure. I still had to walk the whole way home a journey that took more than a year, assisted greatly by medicine, therapy and the support of many people.

FINDING MY PLACE AGAIN IN MY Family took some time. When her bedtime approached on my first night home from the hospital, Keara announced, "I don't need you to tuck me into bed anymore. I do it myself now." For several weeks, no one raised a voice or a broke a rule. I was being watched very carefully. At some point, my daughter must have experienced a critical mass of the old me. She started challenging me again, testing the limits of my authority and my capacity for following through.

Over the course of that year, I had to struggle with self-recriminations about the ways I had failed the people I loved. I was ashamed that I'd been unavailable to Keara and embarrassed that she had seen me so vulnerable. As a psychologist whose profession has historically enjoyed the sport of mother-bashing, it was easy to revert to it myself. Keara would be ruined for life and it would be all my fault.

For a long time after my hospitalization, my daughter dropped her middle name, Manning, and began making it clear that her name came only from my husband, Keara Depenbrock. I knew how important it was for her to see herself as separate from me currently but more important, in the future. It was helpful for my husband to point out to me that although some of it was due to my depression, it was also a normal function of adolescence. When she wrote, "While I have a lot in common with my mother, I have inherited my father's mental health," I was able to see it as a fact as well as a wish.

Over the next several years, I marveled at my child's blooming, despite the scarcity of light in our house at a critical point in her development. Keara later remembered: "My mom's depression was definitely an impediment to us being close at the time. Because she wasn't available to me, and because something so horrible was happening inside of her, it was really hard for her to have this great relationship with other people. I think that she spent all the time and energy she had with me and for me but it wasn't as much as I wanted. I don't blame her for that. She didn't make a choice to be that way. But sometimes I'd get really frustrated and impatient with her anyway."

I recalled psychoanalyst D.W. Winnicott, one of the less judgmental voices in the psychological wilderness, who disputed the necessity of a perfect mother for a child's healthy development, substituting the more attainable standard of "good-enough mother." My faith in Winnicott was confirmed the night my daughter invited me back into

her room for the nightly ritual that had taken so much effort only months before. Now, smoothing her rumpled sheets, straightening her comforter to her exact specifications and rubbing her back with the precise level of finger pressure were gifts, not burdens.

Depression and I are not finished with each other. Four years ago, two years after my first round of ECT, I started sliding in the same dangerous direction. This time, we all saw it coming. If I didn't improve quickly, we knew the plan. This time, I had more ECT treatments, on an outpatient basis. I left for the hospital in the morning, after I'd seen Keara off to school, and I was back before she returned home. Life was not business as usual, but we managed the details with the help of our families and friends.

With the addition of a mood stabilizer (lithium), which I had refused after my first ECT, I have since enjoyed the best years of my life. They have also been the best years of my relationship with my daughter. There was something in the combination of vulnerability and stability that protected us. She saw me go to hell. Exit she was there for the return trip as well. Her fears of depression invading our family again were confirmed so quickly that in some ironic way she got to really learn the drill and find comfort in the evidence that our plans worked. We both learned that lousy things can happen and that they can be so bad and so powerful that they stand good solid relationships on their heads.

The differences between Keara and me are clear. Temperamentally, she resembles my husband and my mother, not me. That knowledge frees her from having to deny the ways in which we are so alike. She can claim our similarities without the fear of turning into me. Several months ago, at the end of her senior year, she came home, leaned against the kitchen counter while I peeled carrots and described having to fill out a form with her name exactly as she wanted it on her high school diploma. "I was afraid it wouldn't all fit," she told me.

"Yeah, Keara Depenbrock is a mouthful," I replied.

"No, Mom," she laughed, "it's worse than that. My real name, Keara Manning Depenbrock."

Our children inhale our imperfections and failings as easily as our love. Perhaps they are meant to. How else will they ever learn to tolerate themselves? My goal is no longer to make a perfect impression. Now, I'm shooting for an imperfect impression and helping my daughter deal with it. I look ahead and hope that she is spared the torment of severe depression. I think she will be. But on the chance that she might get lost in it, or in any of the other ways life tests our faith and our patience and our endurance, I wish for her exactly what she gave to me: a sweet voice in the distance that penetrates her darkness and calls her gently toward home.

Martha Manning, Ph.D., is the author of Undercurrents: A Life Beneath the Surface and Chasing Grace: Reflections of a Catholic Girl, Grown Up, both published by HarperCollins San Francisco. Address: 716 S. George Mason Drive, Arlington, VA 22204.