Subsequently a randomised but uncontrolled observational study from our PMS clinic indicated that PMS sufferers could have the same beneficial response to 100 mcg patches as they do with the 200 mg dose. They also have fewer symptoms of breast discomfort, bloating and there is less anxiety from the patient or general practitioner about high dose oestrogen therapy.(22) 21 day progesterone assays in the patients receiving 100 mcgs showed low anovulatory levels prompting the intriguing question that even this moderate dose might reliably suppress ovulation and be contraceptive. Clearly, a great deal of work must be done before we can suggest that this treatment is effective birth control but it is of great importance because many young women on this therapy for PMS will be pleased if it also was an effective contraceptive. This is a study which needs to be conducted.
When I reflected on this curious alteration of my consciouness—and I was baffled enough from time to time to do so—I assumed that it all had to do somehow with my enforced withdrawal from alcohol. And, of course, to a certain extent this was true. But it is my conviction now that alcohol played a perverse trick on me when we said farewell to each other: although, as everyone should know, it is a major depressant, it had never truly depressed me during my drinking career, acting instead as a shield against anxiety. Suddenly vanished, the great ally which for so long had kept my demons at bay was no longer there to prevent those demons from beginning to swarm through the subconscious, and I was emotionally naked, vulnerable as I had never been before. Doubtless, depression had hovered near me for years, waiting to swoop down. Now I was in the first stage—premonitory, like a flicker of sheet lightning barely perceived—of depression’s black tempest.
The morbid condition proceeded, I have come to believe, from my beginning years—from my father, who battled the Gorgon for much of his lifetime, and had been hospitalized in my boyhood after a despondent spiraling downward that in retrospect I saw greatly resembled mine. The genetic roots of depression seem now to be beyond controversy. But I’m persuaded that an even more significant factor was the death of my mother when I was thirteen; this disorder and early sorrow—the death of a parent, before or during puberty—appears repeatedly in the literature on depression as a trauma sometimes likely to create nearly irreparable emotional havoc. The danger is especially apparent if the young person is affected by what has been termed “incomplete mourning”—has, in effect, been unable to achieve the catharsis of grief, and so carries within himself through later years an insufferable burden of which rage and guilt, and not only dammed-up sorrow, are a part, and become the potential seeds of self-destruction.
These matters in any case interest me less than the search for earlier origins of the disease. What are the forgotten or buried events that suggest an ultimate explanation for the evolution of depression and its later flowering into madness? Until the onslaught of my own illness and its dénouement, I never gave much thought to my work in terms of its connection with the subconscious—an area of investigation belonging to literary detectives. But after I had returned to health and was able to reflect on the past in the light of my ordeal, I began to see clearly how depression had clung close to the outer edges of my life for many years. The sovereign protection of alcohol always kept it at bay; I banished fear through self-medication. Suicide has been a persistent theme in my books— three of my major characters killed themselves. In rereading, for the first time in years, sequences from my novels—passages where my heroines have lurched down pathways toward doom—I was stunned to perceive how accurately I had created the landscape of depression in the minds of these young women, describing with what could only be instinct, out of a subconscious already roiled by disturbances of mood, the psychic imbalance that led them to destruction. Thus depression, when it finally came to me, was in fact no stranger, not even a visitor totally unannounced; it had been tapping at my door for decades.
By far the great majority of the people who go through even the severest depression survive it, and live ever afterward at least as happily as their unafflicted counterparts. Save for the awfulness of certain memories it leaves, acute depression inflicts few permanent wounds. There is a Sisyphean torment in the fact that a great number—as many as half—of those who are devastated once will be struck again; depression has the habit of recurrence. But most victims live through even these relapses, often coping better because they have become psychologically tuned by past experience to deal with the ogre. It is of great importance that those who are suffering a siege, perhaps for the first time, be told—be convinced, rather—that the illness will run its course and that they will pull through. A tough job, this; calling “Chin up!” from the safety of the shore to a drowning person is tantamount to insult, but it has been shown over and over again that if the encouragement is dogged enough—and the support equally committed and passionate—the endangered one can nearly always be saved. Most people in the grip of depression at its ghastliest are for whatever reason, in a state of unrealistic hopelessness, torn by exaggerated ills and fatal threats that bear no resemblance to actuality. It may require on the part of friends, lovers, family, admirers, an almost religious devotion to persuade the sufferers of life’s worth, which is so often in conflict with a sense of their own worthlessness, but such devotion has prevented countless suicides.
Depression afflicts millions directly, and many millions more who are relatives or friends of victims. As assertively democratic as a Norman Rockwell poster, it strikes indiscriminately at all ages, races, creeds, and classes, though women are at considerably higher risk than men. The occupational list (dressmakers, barge captains, sushi chefs, Cabinet members) of its patients is too long and tedious; it is enough to say that very few people escape being a potential victim of the disease, at least in its milder form. Despite depression’s eclectic reach, it has demonstrated with fair convincingness that artistic types (especially poets) are particularly vulnerable to the disorder—which in its graver, clinical manifestation takes upward of 20 percent of its victims by way of suicide. Just a few of these fallen artists, all modern, make up a sad but scintillant roll call: Hart Crane, Vincent Van Gogh, Virginia Woolf, Arshile Gorky, Cesare Pavese, Romain Gary, Sylvia Plath, Mark Rothko, John Berryman, Jack London, Ernest Hemingway, Diane Arbus, Tadeusz Borowski, Paul Celan, Anne Sexton, Sergei Esenin, Vladimir Mayakovsky—the list goes on. (The Russian poet Mayakovsky was harshly critical of his great contemporary Esenin’s suicide a few years before, which should stand as a caveat for all who are judgmental about self-destruction.) When one thinks of these doomed and splendidly creative men and women, one is drawn to contemplate their childhoods, where, to the best of anyone’s knowledge, the seeds of the illness take strong root; could any of the m have had a hint, then, of the psyche’s perishability, its exquisite fragility? And why were they destroyed, while others—similarly stricken—struggled through?
The economy has been in disarray. People have been out of work for years. The banks have been running out of money. It sounds a lot like the Great Depression in the United States. But it is Greece – and in some ways, the situation is worse.
The clue to the use of oestrogens came with the important and somewhat eccentric paper by Klaiber (2) who performed the placebo controlled study of very high dose oestrogens in patients with chronic relapsing depression. They had various diagnoses and were both premenopausal and postmenopausal. They were given Premarin 5 mgs daily with an increase in dose of 5 mg each week until a maximum of 30 mg a day was used. There was a huge improvement in depression on these high doses, (figure 1), but this work has not been repeated because of anxiety over high dose oestrogens.
This condition is mentioned in the fourth century BC by Hippocratic but became a medical epidemic in the nineteenth century. Victorian physicians were aware of menstrual madness, hysteria, chlorosis, ovarian mania, as well as the commonplace neurasthenia. In the 1870's Maudsley(3), the most distinguished psychiatrist of the time, wrote " The monthly activity of the ovaries which marks the advent of puberty in women has a notable effect upon the mind and body; wherefore it may become an important cause of mental and physical derangement " This and other female maladies were recognised, rightly or wrongly, to be due to the ovaries. As a consequence bilateral oophorectomy - (Battey's operation(4)) - became fashionable, being performed in approximately 150,000 women in North America and Northern Europe in the 30 years from 1870. Longo(5), in his brilliant historical essay on the decline of Battey's operation, posed the question whether it worked or not. Of course they had no knowledge of osteoporosis and the devastation of long-term oestrogen deficiency, therefore, on balance the operation was not helpful as a long-term solution but it probably did, as was claimed, cure the "menstrual/ovarian madness" which would be a quaint Victorian way of labelling severe PMS. The essential logic of this operation was to remove cyclical ovarian function but happily this can now effectively be achieved by simpler medical therapy. Only in 1931 was the phrase 'premenstrual tension' introduced by Frank(6), who described 15 women with the typical symptoms of PMS as we know it. Greene and Dalton extended the definition to 'premenstrual syndrome' in 1953 (7), recognising the wider range of symptoms.
Women of the Depression Women stayed at home, tended to their children, did the best they could as far as cooking, and tried ot stay busy and make the most out of the essentials in the households.
Severe premenstrual syndrome (PMS) is a poorly understood collection of cyclical symptoms, which cause considerable psychological and physical distress. The psychological symptoms of depression, loss of energy, irritability, loss of libido and abnormal behaviour as well as the physical symptoms of headaches, breast discomfort and abdominal bloating may occur for up to 14 days each month. There may also be associated menstrual problems, pelvic pain, menstrual headaches and the woman may only enjoy as few as 7 good days per month. It is obvious that the symptoms mentioned can have a significant impact on the day-to-day functioning of women. It is estimated that up to 95% of women have some form of PMS but in about 5% of women of reproductive age they will be affected severely with disruption of their daily activities. Considering these figures it is disturbing that many of the consultations at our specialist PMS clinics start with women saying that for many years they have been told that there are no treatments available and that they should simply "live with it". In addition many commonly used treatments of PMS particularly progesterone or progestogens have been shown by many placebo controlled trials not to be effective. In fact they commonly make the symptoms worse as these women are progesterone or progestogen intolerant.