Huang Meng-hui, who is married and lives in Kaohsiung, helps her husband run two of his shops, and also does all the housekeeping every day. Eight years ago, when her mother passed away, she began to experience a heavy pulse, pressure on the chest and other such symptoms. Gradually, she felt as though her batteries had run down, with less and less energy. Huang recalls, "Even walking along the road put pressure on my heart."

She spent months going from clinic to hospital to clinic for consultations, "I went to Western hospitals for heart monitoring, and the doctor said nothing was wrong. I went to Chinese hospitals and the doctor said it was anemia and lack of qi . Everyone said there was nothing wrong with me," says Huang Meng-hui, "but I really was in pain." This pain, incomprehensible to anyone else, was so bad that she ran away. "I was sitting on the train, and I suddenly made for the door. I just wanted to jump out and end it all."

Luckily, she was pulled back by someone and went home safely to her parent's house. With the support of her family, and having met someone who understood psychological illness, she was advised to go to a psychiatric clinic. Through medication, she was finally able to leave the combined anxiety and dread of her depression behind her. Today, she is out of its shadow, and is even a participant in the Easy Mind Association, a support group at Chang Gung Memorial Hospital in Kaohsiung. There she counsels, assists and supports others with the illness.

Invisible killer

In 1989, Taiwan University Hospital professors Yeh Ying-kun and Hu Hai-kuo undertook a survey of the surge of psychological illness in Taiwan. Their statistics show that psychological illnesses are present in 20.56% of the general population, of whom 2.8% suffer from depression.

"Over the past ten years, although there has been no further survey to provide proof, clinical evidence and the state of society would seem to indicate that the numbers are constantly increasing" says Hu Hai-kuo, who is now director of Taiwan University Hospital's Psychiatric Department.

Lou Ru-pin, Director of the Psychiatric Department at Veterans Hospital, points to statistics from abroad as an indication that the actual incidence of depression is probably higher than we imagine. The likelihood that someone might suffer from depression in their lifetime is 15%. Moreover, due to physical factors, the probability that women may suffer from depression is twice as high.

Apart from the ever-increasing trend towards depression, what alarms the medical community is that those suffering from depression are strongly inclined to suicide.

Recently this phenomenon has been seen in domestic news round-ups, where middle-aged men suffering from depression have committed suicide. For example, at the beginning of this year a staff member of the Central Bank thought to be suffering from depression committed suicide. The year before last, a judge in Kaohsiung, unable to stand suffering any longer, jumped to his death. Many of these people are the sole support for their families, and their suicides plunge entire families into distress. Unless relatives are able to throw off the dark shadow in time, the tragedy is likely to be re-enacted.

Lou Ru-pin quotes from his statistics, "Dividing these cases into attempted suicide and successful suicide, 20% of persons who attempt suicide are suffering from some form of mental illness; in successful suicides, 70 to 90% suffer from mental illness." Lou further notes that depression is the most common form of mental illness.

Depression has not only become a major cause of suicide in Taiwan. The World Health Organization's latest report warns that depression will become one of the 21st century's three greatest diseases. Their research predicts that by 2020, depression, currently ranked fourth in terms of cost to society, will jump into second place, accounting for 15% of illness worldwide.

Long-term blues lead to depression

In the opinion of Wen Jung-kwang, chairman of the Department of Psychiatry of the Chang Gung Memorial Hospital in Kaohsiung, "Because of its wide prevalence, the high incidence of suicide, high medical costs, and the way it detracts from job performance and enjoyment of life, it is entirely apt to describe depression as a killer." Wen calls for a hard look at the real costs to the health care system and society, and suggests that the burden of depression may match that of high blood pressure, diabetes or other chronic illnesses.

So, what exactly is depression? What are its causes? How do you know if you have a tendency towards it? Can it be prevented?

Emotional ups and downs are a fact of life. There are high and low tides, but usually negative emotions such as unhappiness, melancholy and pain don't last. If you experience long-term blues, though, it could be depression.

Again, if feelings of anger, hurt and depression feature in the emotions too long (over three month, for example), this too could well be depression. In such cases, friends and relatives should take note, and the sufferer should go for a check-up as soon as possible.

The medical world classes depression as belonging to dysfunctional psychological illness (others include panic, anxiety, dread, compulsion etc.). It is a type of physical and mental illness, in which physical, emotional and mental states are affected.

The most obvious symptom of sufferers is negative emotion. It often involves a furrowed brow, even a tearful face, and lack of interest in anything and lack of sexual desire are common. Often, there is also unusual behavior, for example seeing three cinema films in succession, restlessness, over-eating and drinking, inability to sleep. Most obviously, there is a constant return to negative thoughts, such as powerlessness, lack of hope, feelings of worthlessness, futility, and of burdening others, so much so that sufferers often turn to suicide to as the only way out. Says Lou Ru-pin, "Particularly from the middle of the night until dawn, they toss and turn, unable to sleep, troubled by thoughts like, 'I'm useless' 'I'm a burden to my family' 'I should just die and get it over with.'" These negative emotions also present a host of difficulties for friends and relatives.

Troubled in body and spirit

What mystifies people is how the earliest symptoms are often manifested physically, rather than psychologically.

"Chinese, including Taiwanese, can't express psychological illness, and so it tends to come out physically, as dizziness, headaches, raised pulse, pressure on the chest, rapid breathing, stomachache, backache, abnormal appetite, and so on. So in the first instance, they will go for check-ups and medication to all sorts of departments of internal and external medicine," explains Lee Yu, staff psychiatrist at the Department of Psychiatry at Chang Gung Memorial Hospital. Lee is the author of the research report Inquiry into the Behavior of Depression Sufferers from a Cultural Perspective, which explains why in Taiwan depression is often not treated medically.

Many Taiwan people are still superstitious and believe in traditional religions like Taoism. When they do see a doctor at a clinic, they say things like "I'm possessed by an evil spirit." "A dark shadow is following me." or "The fengshui is not right." They go all over the place seeking gods and divination, and having themselves exorcised. This prolongs inappropriate treatment and can exacerbate the illness.

Says Lou Ru-pin, "There are so many symptoms of depression. If they are minutely analyzed, there are at least 45 types." With so many types of symptoms, there aren't the clear distinctions that you get in other types of illness. This makes depression the most frequently overlooked diagnosis.

Based on clinical evidence, depression is divided into three types depending on the severity of symptoms: severe depression, mild depression and manic depression.

In cases of severe depression, the manifestation is like a storm, a torrential outpouring that almost swallows the person up.

American travelogue author Lee Yu entered a bleak period after her husband, the novelist Kuo Sung-fen, had a stroke and required intensive care. She became severely depressed two years ago.

Her symptoms included complete loss of interest in anything, especially anything that she had previously taken pleasure in. She also became indecisive. She could be very clear in her mind as to what she should be doing and how to do it, but she just stayed passively in one place all day, feeling that nothing had any interest or meaning. She was completely without the will to act.

A slow death

Looking back on those days fighting a nameless dark terror, she feels as though she went through hell itself. Here is what she wrote at the time: "Now, I'm both disturbed and uncaring. I feel panic-stricken all day. All the certainties that I so firmly believed in have been shaken. All my long-term writing has been put aside. The person I am now can't even cope with doing everyday things like buying food and cooking."

Although severe depression is very disabling, even mild depression is hard to throw off. It is frequently not seen as an illness, especially as it presents no immediate danger. The emotions associated with mild depression are not very forceful and the physical and mental symptoms are not so obvious. It is more like the persistent fog of the rainy season, damp and clammy, gray and misty. There are feelings of powerlessness, lack of flavor and disinterest which cannot be brushed away, webbing the soul with their threads. In the long term, the will to act is gradually sapped.

In manic depression, apart from the symptoms of depression, there is also corresponding excitement, passion, restless movement and other unsteady emotions. The highs and lows are at clearly opposite poles. For example, during the day a manic-depressive person might devote himself to his job with great zeal, making a torrent of suggestions, only to return home in the evening and feel as though sunken in a deep abyss from which there is no escape.

Wen Jung-kwang says that although depression affects both young and old (recently there was even a case involving a five-year-old), depression occurs most commonly between the ages of 31 and 50. This is still the prime of life, yet sufferers frequently choose suicide. Even when a person doesn't go so far as suicide, depression destroys physical and emotional health, hampers job performance, and detracts from one's personal and social life.

According to Lou Ru-pin's research, on average Chinese people will visit a psychiatric department for proper treatment 60 weeks after developing depression, double the time it takes Americans to seek help. "During this time of a year or more, sufferers have probably been to departments of both internal and external medicine and undergone all sorts of diagnostic tests and have failed to find the cause of their illness." He says that from the point of view of costs of treatment, this sort of spending is not only extremely wasteful, but the pain that the patient has to endure is even harder to estimate.

Taking a toll on work and family

"Whether depression is severe or mild, it is not something that can be cured in just a few days. If a patient has not received proper treatment the symptoms may persist for many weeks or months, or even years," Lou Ru-pin says, "but in common with other psychological illness and in contrast to physical illness, depressed persons don't get much support from society." He takes as an example the fact that a patient with a heart condition and a patient with a psychiatric condition are treated with very different attitudes in hospital. The patient with a heart condition gets lots of visits from friends and relatives, whereas those visiting depressed persons are markedly fewer.

Clothing designer Lee Chia-yin contracted dengue fever in 1987 and developed paranoia and depression. Both at work and at home she began to suffer from bouts of mental illness that changed her from a lively, outgoing personality into a shrinking violet. Allergy to her medication caused her to walk unsteadily and gave rise to bouts of dizziness, loss of memory, weight gain and other side effects, making her unable to maintain the quality of her work.

"What upset me most was people's unforgiving attitude. They thought I was just not getting it together, and that I was being lazy." She ended up divorced as a result, and is today fighting her severe depression and panic all alone.

Pressure, personality and inheritance

Another aspect of depression which gives rise to misunderstanding is its cause.

According to Lou Ru-pin, early research assumed that depression was the result of pressure. In the 1960's, for example, there was research indicating that sufferers from depression were likely to have faced more pressure in the previous half year than non-sufferers. All types of pressures-divorce, debt, death of a family member, and so on- were likely to give rise to depression. They were "unwelcome, unwanted, and unavoidable, and yet the person had no way of gaining support from society."

There are also people who believe that depression stems from personality. There are some patients who always look at things from a negative point of view. In fact, however, "pressure and personality only account for about 10-15% of depression. The other 85% of cases," Lou Ru-pin, "are inexplicable." For example, in this century there have been many great disasters-two world wars, the Korean war, the Vietnam war-all long and cruel wars. According to research, however, cases of depression didn't increase as a result.

Later research showed that cases of depression caused by external factors, such as pressure and personality, were in fact only a small number of the total; 85% of cases were in fact related to physical problems-the underlying causes of depression. "There are families in which depression runs like a hereditary disease, which can manifest itself in many different ways, including migraines, alcoholism, pre-menstrual tension, and pre- and post-partum depression. "All these problems," says Lou Ru-pin, "are inherited symptoms related to depression." There are many sufferers who can trace their depression back to childhood injuries (both psychological and physical) which may have caused brain damage. Of course, there are some patients who had physical problems to start with who became even more vulnerable to the illness due to personality and outside pressures.

Mental vitamins

In recent years the medical community has gradually lifted the veil on depression's triggers and found that the amount of dopamine, serotonin, epinephrine and other substances in the brain's nerve cells are all involved.

Therefore, although depression is hard to shake off, the medical community's hard work in the past decades has resulted in methods of treatment which have yielded significant success.

Lou Ru-pin indicates that since the gradual emergence of medical treatment for depression in the 1950's, drugs used today in the treatment of depression have minimal side effects. Fluoxetine, for example, is seen as a 'mental vitamin' that anyone can use whether they are depressed or not. Thus today there are very standard appropriate treatments to combat depression and patients no longer have to hide their pain in loneliness at home.

Having said that, according to follow-ups on patients, it was found that if their depression diminished and they stopped or cut down on their medication, there was a 75% likelihood of their illness reasserting itself within three years. Thus depression, like high blood pressure or diabetes, requires a lifetime of watchfulness and treatment as a chronic illness.

Group therapy and support

Apart from medication, psychiatric therapy is seen as an effective treatment for depression. "Depressed persons commonly have habitual negative thoughts, and always see the bad side of things, but psychotherapy can alleviate sufferers' symptoms," observes the attending doctor at the Psychiatric Department of Taipei Adventist Hospital, Chen Jun-kuang. Moreover, with the guidance and support of a professional psychiatrist, patients gain necessary information during the course of their treatment to enable them to stick firmly to it.

The sad thing, he says, is that "the insurance cover given domestically to psychiatric treatment is comparatively low, which affects the number of psychiatrists taken on by a hospital, and the therapy offered." In addition, in order to return to society, depressed persons need the assistance of social and rehabilitation workers, "which are even less sufficiently offered."

However, there is a small number of specialized hospitals for sufferers of depression and other mental illness, and these have designed a full treatment service-psychiatrists, psychotherapists, social workers, rehabilitation facilitators, and care organizations. The Chang Gung Memorial Hospital has a specially designed "pressure ward" where sufferers can get away from the causes of their pressure and stay in hospital to concentrate on their treatment. Every day they have classes where they practice Chinese methods of calming and healing such as meditation and qigong breathing exercises. There are also mutual aid associations such as the Ai Hsin Association and the Easy Mind Association where members give each other encouragement and support.

Hu Hai-kuo emphasizes that whether a sufferer or not, everyone should pay attention to their mental health as a matter of course. For example, avoid unnecessarily heavy pressure at work, follow a way of life that allows for physical and mental balance, cultivate a leisure activity or interest that allows the brain to relax, learn suitable ways of expressing and adjusting emotions and so on. "Contemporary medicine is realizing more and more how important the brain is. It is the body's director, and everyone must understand how to look after it. This is the way to avoid mental illness."

A second spring

For depressed persons, the ultimate goal is to rebuild their lives and return to society. "We are all seen as mental cases, so it's not easy to find work, and very difficult to find partners," laments 28-year-old Lin Chi-hao. At 19 he became quite unable to sleep, and in class would suffer symptoms such as panic and fear for no reason, but by means of strong will and hard effort, he passed his university entrance exams with good marks. Through sustained treatment his condition is under control, but work and his professional development leave him frustrated, and his personal life is far from ideal. "Every time I find a girlfriend, when I level about my illness, they just withdraw." So Lin Chi-hao now imposes a taboo about revealing his past and his illness.

Through treatment and her own unstinting effort, author Lee Yu is slowly recovering from depression and picking up her old habits again, putting her splintered life together, and working on getting back into the world. "I hope that after all this chaos I can find a tranquil place and start living to the fullest again."

"The process will be very tough, but as long as you believe in yourself, and are willing to persist, you can get out of that black fog, and live as yourself again." So says Cheng Shen-fen. After five years of treatment for depression, she is very willing to share her experience, having lived through what she describes as living death-the break-up of her marriage, financial hardship and other frustrations. Happily, after undergoing long-term treatment, accepting religious faith, and participating in Taipei Mackay Memorial Hospital's business consultant volunteer work, she has found her confidence and her self. Today, she has not only courageously started her own business and career, but also takes part in the Tzu Chi Buddhist Association and is responsible for volunteer work at the Taipei branch, assisting people who suffer from depression.

"Before, I contemplated suicide several times. I wanted to finish off my pain and lack of desire for life, but now I am so glad that I didn't do anything stupid, otherwise I wouldn't have this joy at having come out of the darkness and into the sunshine, or this satisfaction and pride at having rebuilt myself."

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(drawing by Tsai Chih-pen)

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Most people think that depression is just an emotional low or a character trait, but the medical community warns that it can lead to serious physical and psychological illness-clinical depression. (photo by Diago Chiu)

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In today's lonely, fast paced, noisy, and uncertain society, everyone is liable to feelings of depression, fear, anxiety and agitation. If these are not faced squarely and treated, they may lead to serious problems.

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Treatment for psychological illness requires a team effort. The photo shows the Psychiatric Department's 'pressure ward' team at Chang Gung Memorial Hospital, Kaohsiung. The team comprises psychiatrists, psychologists, rehabilitation workers, social workers and care staff.

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In addition to medical treatment, in recent years many other activities for regulating the emotions and balancing mind and body have been included in the treatment of depression. Art therapy is one example.

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Only those who have come through depression can fully understand what sufferers are going through, so many patients' organizations establish mutual help groups like the Ai Hsin Association and the Easy Mind Association. Members give support and encouragement to help each other overcome depression and regain the ability to smile with joy once more.

In today's lonely, fast paced, noisy, and uncertain society, everyone is liable to feelings of depression, fear, anxiety and agitation. If these are not faced squarely and treated, they may lead to serious problems.

Treatment for psychological illness requires a team effort. The photo shows the Psychiatric Department's 'pressure ward' team at Chang Gung Memorial Hospital, Kaohsiung. The team comprises psychiatrists, psychologists, rehabilitation workers, social workers and care staff.

In addition to medical treatment, in recent years many other activities for regulating the emotions and balancing mind and body have been included in the treatment of depression. Art therapy is one example.

Only those who have come through depression can fully understand what sufferers are going through, so many patients' organizations establish mutual help groups like the Ai Hsin Association and the Easy Mind Association. Members give support and encouragement to help each other overcome depression and regain the ability to smile with joy once more.