Spiritual Vital Signs
by Mike Litrel, M.D.

malaise about life, feeling bad without being able to put a finger on the reason, feelings of self-dissatisfaction, stress, fatigue. Blood tests are ordered to rule out hormonal imbalances or other types of problems. But chances are these will come back negative.

The medical establishment has come up with a diagnosis called "depression." The diagnosis has reached epidemic levels in the United States. It is almost a diagnosis of exclusion — that is, a catch all label for patients with complaints such as Mrs. Mulken's, without other identifiable problems.

But what is depression? What causes it? And why do increasing numbers of people suffer from it?

"Mood Disorders," Chapter Six of Clinical Psychiatry for Medical Students discusses the diagnosis and treatment of depression. Here it states: "the hallmarks of depression are a subjective sense of dysphoria (sadness) and an inability to derive pleasure from life (anhedonia)." Theories about why we experience depression are practically numberless. Many center around the idea that the chemical messengers (neurotransmitters) between nerve cells have altered. That is why the most popular anti-depressants prescribed today are the selective serotonin reuptake inhibitors (SSRI's) — they increase the concentration of a chemical messenger called serotonin.

I have prescribed these medications many times. Indeed, they can help people feel better. And new anti-depressants come out every year. Drug representatives visit my office every day to tell me why their drug is better than the others.

But is taking a pill the answer?

Nowadays, it has become the answer for everything. In the past 50 years, the arsenal of pharmacology has proliferated in power and scope. At the beginning of the 20th century (or in underdeveloped countries today), it was quite common for parents to lose a child to infection. Pharmacology has brought us antibiotics and vaccinations which have saved literally millions of lives from infectious diseases. It has given us medications to treat common disease, such as high blood pressure or peptic ulcers, further increasing our life spans.

It has provided us with countless over-the-counter drugs for everything from an upset stomach to a runny nose. We live in the Age of Drugs: there is a medication for almost everything that ails us.

As a physician who has done his share of both operating and prescribing, I worry that the treatment strategies for depression are flawed. Surgery deals with the problems that are well defined — there is nothing subtle about a hernia or a tumor. You perform the operation, the problem is fixed, the symptoms go away.

Depression causes terrible suffering. We can treat the symptoms with medications and cross our fingers that the side effects are better than the disease. But no one understands what causes depression in the first place, or exactly how the medication works.

A woman may have terrible abdominal pain from a cancer growing in her body. She can find relief from pain with a narcotic. But her cancer has not been treated. Eventually she will die. In order to receive treatment, the source of her pain must be uncovered, the underlying cause addressed — not just the symptoms.

Is it possible that by treating depression with medication we are sometimes covering up the underlying problem? Are we doing more harm than good?

I will continue this in next month's story. Until then, focus on the good side of life.

Dr. Litrel is in practice at Cherokee Women's OB/GYN in Woodstock and Canton and is a Clinical Assistant Professor at Emory University School of Medicine. He lives in Towne Lake with his wife Ann and their two sons Tyler and Joseph. (Atlantalitrels@CS.com)

Twenty years ago, Mrs. Mulken delivered a nine pound baby after pushing for two hours. That was the start of her problem.

I'm not referring to parenting issues or rising college tuitions. My patient, Mrs. Mulken, delivered a child the natural way and that "natural" act, surprisingly to some folks, was the source of huge physical discomfort twenty years later. She walked into my office with a litany of complaints: leaking every time she coughed or sneezed, an aching back, and the strange sensation that her bottom was "falling out."

Patients come to their doctor with all kinds of problems. The good news about Mrs. Mulken's was that it was fixable: a prolapsed uterus, bladder and rectum are restored with an operation. We scheduled her for the O.R., and I optimistically told her she could expect to feel much better very soon.

Indeed, six weeks after surgery, Mrs. Mulken's symptoms were gone. It was wonderful to hear her amazement at how much better she felt. I read through her operative report while she dressed after her post-op exam. Her surgery had gone exactly as planned, the planes of tissue unfolding beautifully under the incision, with hardly any blood loss. It had been a delightful two hours in the operating room, the kind of experience that puts me in a good mood the rest of the day.

"Our patients get better despite what we do, not because of what we do," a surgical mentor used to say. A doctor is a witness, not an author, to the miracle of God's healing. Still, the fun part of the job is watching people get better, and a feeling of satisfaction came over me despite myself as I returned to Mrs. Mulken's room with the intention of sending her on her way. I had done the work I was supposed to do, and now she was better.

But something seemed wrong. She hesitated when I asked her what was bothering her. It was nothing, she assured me. With a little encouragement, however, she opened up. For many years she had felt bad about herself — in fact, as long as she could remember. Maybe it was her weight. She wasn't certain. If she could just lose some weight. But she had tried every diet and exercise program with no success. And sometimes she had trouble taking a deep breath — like she was suffocating. She just didn't feel happy anymore. She hated the stress she was under. She wanted to know if there was a pill that could fix her, that could make her happy again. She had seen a commercial on television.

A feeling of disappointment came to me. The success of her operation had made me happy. We had diagnosed her problem and fixed it in the operating room. But there were other things wrong here — things not so obvious as an anatomical defect, things not fixable with surgery and perhaps, not fixable with a pill either.

I have heard Mrs. Mulken's complaints echoed by thousands of patients. A feeling of