[Doctor:] That drawing was doneby [?] in the 16th century,

and it is still a good guideto the diagnosis of depression.

The turned-down corners of the mouth,the typical triangular,

variegate fold over the eye,the furrowed brow,

the hurt look.

Depression is an emotionas old as mankind.

Perhaps this is the reason whywe sometimes fail to look at it

as a disease, which it often is.

Mourning and grief are human concerns,not clinical ones, but when there seems

to be insufficient reasonfor the patient feeling so depressed

or if the symptoms are too severeor if they last too long,

then we are facedwith a pathological depression,

the typical symptom picture,

and with indicationfor medical treatment.

It is a sad, despairing mood,

which is a real core of all depressions.

Depression, which will have to be recognized

and treated like other clinical syndromes,for instance,

shock or congestive heart failure.

If we fail to recognizeand treat depressions as such,

nothing we do for our patientwill help him.

He may get worse

and there's always a danger of suicidein the background.

Medically, he may be misleading.

In the physiological sense,it describes a primary reduction

of function, but in the clinical sense,

it takes on a more complex meaning

and such opposites may be involvedin the depressive states as excitation

and inhibition,

agitation and retardation.

It matters little for therapy,whether or not the depression falls

into one or another particular diagnostic category.

And for this reason,

in this film, we are not so much concerned

with differential diagnosis,but with the signs and symptoms

of different depressive states.

[Narrator:] This is a severe endogenous depressionin a woman

who has suffered previousmanic depressive attacks.

In general practice,depression seldom appears

with this clarity.

[Doctor:] When is it worse?In the morning?

Or at night?

[Woman:] It's worse in the morning,

it's on me now,it's all the time, I have to [?] .

[Doctor:] It's worse in the morning...canyou sleep?

[Woman:] No, I'm just too scared to go sleeping.

I've had some pills,I slept last night a little bit, but...

[Doctor:] With pills, you can sleep?

[Woman:] Yes, I slept a while last nightwith the four pills.

[Doctor:] You said you are too scared,in which way?

Are you afraid of anything in particularor do you just feel so awful that...

[Woman:]I feel so awful all the time,I just concentrate on one thing,

on myself.I don't know what's happened to me?

What's going to happen to me? What's...

that's how I feel.

I can't seem to talk to people,I seem too down all the time.

I can't do anything.

I can't take any interestin life or my family

or anybody around me. I just sit there just like a dumb person.

[Narrator:] This is also the face of depressionalthough it doesn't appear to be.

Some people disguise their real feelingsand unless the physician is on the lookout

for depression,it may announce itself too late.

To miss a depression like this one

can be as dangerous as missing a coronary.

[Doctor:] Why did you come here?

[Woman 2:] Because I tried to commit suicide.

[Doctor:] Yes, I knew that, of course,

but what I don't know is why you triedto do this.

Could you tell us how you did it?

[Woman 2:] I took an overdose of pills.

[Doctor:] A hundred, didn't you?[Woman 2:] A hundred, yes.

[Doctor:] And why did you want to commit suicide?

[Woman 2:] Because I didn't want to face anything.

[Doctor:] This wasn't the first time?

[Woman 2:] No.

[Doctor:] How often did you try?

[Woman 2:] Well, I tried quite a few times.

[Doctor:] Why did you try so persistentlyto take your own life?

It's a difficult question.[Woman 2:] Yes.

I was just desperateand I didn't, I couldn't face

things that had come up,

so I thought the easy way out wasto take pills and it would be all over.

That's what I did.

[Doctor:] You told me the other daythat you have always made

every effort not to showthat you're depressed.

Have you always made ita point to cover-up,

your real your feelings?

[Woman 2:] Yes.

[Doctor:] Why?

[Woman 2:] Well, I guess that's just part of me.

When I was quite young,

for a time I went to a stagewhere I was a real monster.

I tried to get my mother's attention,which I couldn't get.

I would break things and cryand throw tantrums

and it didn't do any good.

Then I realized that my auntsand other people could see how hurt I was,

and I didn't want anyone to see,to be able to tell that I was hurt,

so I just tried to be the opposite.

I didn't care about anythingand it worked.

People believed that I didn't care.

[Doctor:] You learned to do it quite well.[Woman 2:]  Yes.

[Narrator:] With an unmasked pathological depression,

the signs are often clear

and a tentative diagnosiscan be made quickly on the basis

of what you see as soonas the patient walks into the room.

In practice, these target symptomsmay show themselves in a far

more diluted form

and may be missedunless they're deliberately looked for.

Depression shows itselfin the turned-down mouth,

the inability to smile easily,the peculiar fold in the eyelid,

the depressive cast of the face,the wry smile with no enjoyment

behind it,

the hurt look, the dejected attitude,

the lack of spontaneity and animationin movement.

Signs like these,even when far less apparent, should lead

the physician to suspect depression.

A few questions should clinchthe diagnosis.

When appearances don't help,the patient's verbal description

of his mood and feelings must be reliedon entirely.

A symptom of depression is the inabilityto love anyone,

to enjoy anything.

[Man 1:] No, I can't concentrate very much,very little.

[Doctor:] Can you find any other kindof distraction...going to a movie?

or [crosstalk]?[Man 1:] No, I don't feel like, I usually used

to like it very much to go to a movie,to play a game or something else,

but now I have no desire, no feeling,I don't care for it.

[Narrator:] Decrease in mental productivityand reduction of drive

are characteristic symptoms of depression.

[Doctor:] What happened?How do you feel?

[Man 2:] Weak.

[Doctor:] Weak.

Are you tired?

[Man 2:] Tired, yes.

[Narrator:] This is a smiling depression,

so afraid of her depressive thoughts

that she denies them even to herself

because she must fool herselfin order to achieve a composure

that is not very deep,

she may well fool her doctor unlesshe's on the lookout for the disease

of depression.

[Doctor 2:] What did you feel like doingwhen you were alone?

[Woman 3:] Usually, I have to keep busydoing something.

[Doctor 2:] Or else what would you be thinking about?

[Woman 3:] Oh, I don't know.I can't say.

I can't say what I'd be thinking about.

[Doctor 2:] What about when you thoughtabout going to the basement

and doing somethingto get rid of yourself?

What about that?

[Woman 3:] I don't remember thinking about that.[Doctor 2:] You don't remember thinking about that?

[Woman 3:] No.

[Doctor 2:] Do you remember telling me about that?[Woman 3:] No, I don't.

I don't remember.

[Doctor 2:] What do you think when I tryto remind you of it now?

[Woman 3:] No, I don't like to be reminded of it.[Doctor 2:] You don't?

[Woman 3:] No. I don't thoughts like that.

[Narrator;} Self-accusation and self-depreciationare common symptoms,

and always present is the sad,depressive mood.

[Woman 4:] All my senses are dulled, you know,I can't cry.

I haven't been able to cry, well,for months.

I sometimes wish I could have a good cry

because I think it does you good,but I can't cry.

[Doctor:] Would you consider it an illness?

[Woman 4:] Yes, but as I say,I think I brought it on myself.

I know I'm stupid.

It makes me mad when I can't do things properly.

Well, not mad, but it makes mesuch an awful pity.

[Doctor:] Why do you say you knowthat you're stupid?

[Woman 4:] Well, I do such stupid things.

[Doctor:] Do other people say that?

[Woman 4:] No.

[Doctor:] Nobody blames you but you yourself.

[Narrator:] A patient may look depressed and not be.

Here cerebral arteriosclerosisis responsible

for what on examination turns outto be simply confusion.

[Doctor:] Tell me, you know what day it is today?

[Man 3:] No, I don't know.I don't see the calendar.

I can't tell you, I don't see the calendar.

[Doctor:] What month is it?[Man 3:] I don't know.

I can't say because I don't seethe calendar.

I can't say it.

[Narrator:] Depression is the presenceof a deep, profound emotion,

not the absence of emotion.

And what looks like the retardationof depression may prove to be

the simple apathy of schizophrenia.

The depressive knows no peace.

The schizophrenic has no complaints.

[Doctor:] How are you feeling, Jean?

[Jean:] Pretty good.

[Doctor:] Not much wrong?[Jean:] No.

[Doctor:]  You sleep well?[Jean:] Yes.

[Doctor:]  Do you like the company of people,or do you like to be alone?

[Jean:] No, I like people.

[Doctor:] Do you like music?

[Jean:] Yes.[Doctor:] Do you like the movies?

[Jean:] Yes.

[Doctor:] Do you like parties?

[Jean:] Yes.

[Doctor:] Can you smile?

[Jean:] Yes.

[Narrator:] The puzzled rigidity of the catatonic may look very much like the set features

of depression, but the profound disturbance of depression

is missing.

There may be concerns,but there is something else again.

[Doctor:] Why did you come to the hospital?

[Man 4:] Worry, I guess.[Doctor:] Worry?

What did you worry about?

[Man 4:] Well, uh...

[Doctor:] What did you worry about?

Have you forgotten?

[Man 4:] Uhhh...

[Doctor:] Pardon?[Man 4:] Girls.

[Doctor:] Oh, girls.

Early recognition of the depressionin the consulting room is important before

it gets covered upbehind physical symptoms and complaints

which the patient may producein order to explain to his doctor

and to himself why he feels as badlyas he does.

It is this failure to recognizea depression early,

which sometimes leads the physicianand the patient down the long road

of futile investigationsand possibly surgery,

which may prove costly and time-consumingand to which the physician may resort

when he is puzzled and cannot finda reason for his patient's complaints.

This course of action exposes a patientto the dangers of delay in treatment,

and in some cases, to the risk of suicide.

Certainly, elective surgery is contraindicated

in depressive states because of the low general resistance

of the patient.

Very likely, the post-operative coursewould be stormy.

Not only are many psychosomaticsymptoms attributable

to what has been called depressionin disguise,

but also such behavior deviationsas alcoholism or overeating,

even delinquent behavior provesometimes to be the leading symptom

of an otherwise concealeddepressive state.

[Narrator:] Puzzlement and bewildermentover their condition is common

with patients sufferingfrom pathological depression.

They know something is wrong,but they don't know what or why

and they search eagerlyfor physical reasons to explain why

they feel the way they do.

[Woman 5:] Right now, I have trouble

with my stomach,which may be caused by nerves.

[Doctor 2:] Do you ever feel discouraged?[Woman 5:] Yes, I do.

I have crying spells, which I cannot control.

I have trouble with my stomach,which I believe is caused by nerves.

Now, when I came here,I didn't know exactly what was wrong.

They passed me to medical,all the medical was okay in every degree.

Well, you see, it left me in the (?)because I was in the impression, well,

maybe they think that I'm making upthe story or listening to myself,

but I'm not that kind of a person.

[Narrator:] Some patients suffering from depression,which has never been diagnosed as such,

have gone from doctorto doctor looking for relief.

[Doctor 2:] You have been comingto the medical department for quite a time.

You've had blood tests and x-raysand urine tests and bone marrow tests

and everythingand they haven't found anything wrong.

[Man 5:] The hospital, uh, therapy,it's coming three times a week.

[Doctor 2:] Yes, you were coming to physiotherapy

for a long time because of the painin your back even though

they couldn't find out what caused it.

How do you feel?

[Man 5:] It's not feel bad but it's not feellike before.

[Narrator:] When medical treatment has failed,some patients have been subjected

to surgery time after time

with no effect on the underlying conditionof depression.

Depression is a pathological reactionto loss of something one has loved.

It might be through death or it might bethrough loss of money, of youth,

of health, or vigor.

Anything that is meaningfulto the individual.

[Doctor 2:] Can you tell us how you were feelingwhen you first started coming to see me?

[Woman 6:] Well, I'd been feeling awfully depressedfor a very long time.

I cried over the least little thing.

I felt that everybody was against me.

Well, I just couldn't seem to getalong with anybody, that was all.

[Doctor 2:] When did this all start?

[Woman 6:] Well, I think it really startedwhen I lost my baby.

After my husband left me, I lost my baby.

And then, uh,

I had operations there.

I had an operation for a hysterectomy

and it didn't seem to do much good.

I began to feel more and more depressed.

Then I had a third operation there.

I had my last ovary removed and I was critically ill then.

And then, uh,

I don't know, the place, everything around seemed to...

Just couldn't seem to get along at all.

Then I was I had a piece of shrapnelin my knee and I was asked to go

to the Queen Mary Veterans Hospitalto have it removed as I had a cyst.

While I was in there,I just broke completely down.

The doctor there suggestedthat I should come to the Montreal General

and asked me if I was willingto undertake psychiatric treatment, which I did.

[Doctor 2:] So you'd had, what,

three operations really beforeit was really realized

that you were suffering from a depression?[Woman 6:] Yes.

[Narrator:] In old age and with chronic disease,the universal mood of the patient

is often one of depression.

The depression itself can be treatedand relieved.

Emotional comfort can be providedjust as physical comforts are,

with glasses or new teeth.

Raising the mood of depression will allowthe patient to enjoy himself

again and will improve the handlingof his condition.

[Doctor 2:] Well, what do you feel like now?

[Man 6:] Well, [?] I was depressed.I was very happy always.

[Doctor 2:] When did you get depressed?

[Man 6:] When [?][Doctor 2:] Do you think you'll ever get over that?

[Man 6:] I hope that I will do.

[Narrator:] This is a left-sided hemiplegiawith congestive failure and diabetes.

The mood is one of depression.

Although objective improvementof her physical condition can be produced,

the all-important feeling of well-beingwill only result when her depression

is relieved.

[Woman 7:] I'm sitting in the window and cry the whole summer.

Also, I don't usedto that I'm used to being...

[Doctor 2:] Do you cry a great deal?Do you cry often?

[Woman 7:] No, no.I cry like nobody hear what I am myself.

[Doctor 2:] Oh, you cry inside.[Woman 7:] Inside.

I say, god, my god, my god.

[Narrator:] Old age is a rapidly rising problem,and with it is a rise in the incidence

of depression.

Depression has been called a diseaseof general practice and is seen,

but not always recognizedin every consulting room.

[Doctor 2:] What makes you feel better

when you're feeling depressed?

[Man 7:] What makes me feel better?[Doctor 2:] What makes you feel better?

[Man 7:] I don't feel better.

[Narrator:] Alcoholism sometimes resultsfrom self-treatment with alcohol

in an effort to relieve feelingsof depression with habitation resulting.

[Man 8:] I took to the drink, you see,over being so depressed.

Very depressed and melancholyat times, so much worry.

[Doctor 3:] And when you go on these drinking bouts,

I understand that it lasts maybe a weekor two weeks or three weeks

and you drink pretty heavily.

Does it give you any relief?

[Man 8:] It gives you relief at the time,sir, because somee say,

it seems to deaden the feeling,and you forget for a little while

but then when you come to in the morning,it's still with you .

[Narrator:] In the background of all depression isthe risk of suicide,

the overdose of pills,

the cut wrists.

Unless the depression is obvious,which isn't always the case,

it is valuable to have the assistanceof family or friends in arriving

at the diagnosis.

For without a history of the illness,it is difficult to know the change

that has been wrought in the patientby the disease

and to know the normal conditionto which treatment for the depression

will return him.

We are all so familiar with the feelingof depression,

but we tend to accept it simplyas a condition of mankind,

not an illness, which it sometimes is.

An illness which can be treatedand relieved.

There is a great differencebetween the feeling of depression

we all know,

and the one which is at the coreof pathological depression,

and only someonewho's experienced it can describe it.

[Doctor:] You were saying that it was strangeto convince the doctors in the hospital

that you were depressedand they didn't think you were depressed

because you didn't appear to be.

Is that it, even to the psychiatrist?

[Man 9:] That is correct.

[Doctor:] How did you feel?

[Man 9:] I felt terrible because I couldn't seehow I could possibly go back to work

if there wasn't some improvement.

In my state, I couldn't seehow I could possibly go back

to work and keep going.

I had stopped work to go into the hospitalbecause I needed some treatment,

and if they weren't going to give me shockor something, I couldn't see

how I could possibly go and work again.

[Doctor:] There was nothing that you could enjoy?

[Man 9:] Absolutely nothing.

There was no one I could seethat I'd be glad to see.

There was nothing anybody could say...

[Doctor:] That would cheer you.[Man 9:] that would cheer me.

Although, as I've said before,I could still tell a joke.

[Doctor:] Even then?[Man 9:] Even then, I could tell a joke.

[Doctor:] Make other people laugh?[Man 9:] Yes,

because I think the reason for that isthat I'd always been known to be a joker,

and I enjoyed the factthat people enjoyed me telling them jokes

and it would give them a good impressionof me.

I think that was the reason whyI could still tell, I tried to muster up

the strength to tell a story so somebodywould notice me.

[Doctor:] You could do it.

[Man 9:] I could do it, yes, strangely,and then in fact,

some of the nurses remarked how wellI told a story

[laughs] and uh...[Doctor:] How good you were doing, I suppose.

[Man 9:] Yes.

Although others didn't understand meso well and told me to get

the long look off my face.

There was one nurse in particular,of course, I won't mention any names,

but there was one nurse in particularwho I didn't think really belonged there,

in a hospital like that.-[?] .

[Man 9:] Pardon?[Doctor:] Probably she didn't belong there.

[Man 9:] Because I was sitting thereand my face must have been a mile long

but she more or less criticized me for it.

This is much as to say, ah,there's nothing wrong with you.

What are you looking so glum about?

[Doctor:] Did she...[Man 9:] I have to believe that she was right,

that there was really nothing wrongwith me.

All it had to do was be a manand snap out of it.

[Doctor:] That made you feel worse, didn't it?[Man 9:] That made me feel worse.

[laughs]

[Doctor:] That's the sort of thing that peoplewould do or still do quite frequently

when somebody is depressedor looks that way and say, oh,

well just snap out of it,and then the person feels worse

because they thinkthey should and they can't.

[Man 9:] A lot of people, say,"Oh, I feel depressed today."

I think everybody has ups and downs

through the life,but there's no comparison.

I had ups and downs before I ever had oneof these depressions

of which I'm speaking now.

There are no words that can describethe difference between it.

The ordinary ups and downs...[Doctor:] That everyone has.

[Man 9:] that everyone has, because in these upsand downs through life,

you know that tomorrow I'm goingto feel better,

the sun will be shining and so on,but when you're in this type

of depression I speak of,

it doesn't matter whether it's a blackof night or whether the sun is shining,

whether it's pouring rainor whether it's snowing or anything else.

Nothing looks good.

It's all blackness.

It's very difficult.

I think that put a thinginto words though.

There's an old thingabout this place called hell

where bad people go to after they die.

The worst part of what hell is notthe flames,

it's the hopelessness.

I think that is the part of hell

that a person in depression really tastes.

[Doctor:] The hopelessness.[Man 9:] Hopelessness.

Terrible hopelessness that comes over.

Everything's black.

Nothing looks,

you can see there's nothing cheerfulin anything.

All I could see was death.

For instance, I'd say, what's the useof of getting up?

What's the use of eating?I'm only going to die someday anyway?

What's the use of doing anything?

Because it's pointless.

It's all going to end in death

whether I arrange to do it to myselfor whether I just set it out.

[silence]

[Music]