Depression struck, the first time, without warning: Dolores D. was in high school the first time she woke up, absurdly early in the morning, to a world that held only despair.
It hit her again in college, and twice when her children were young. Sleep fled first, and then gloom set in. She'd "muddle through" hopeless days with a general, unfocused anxiety that mounted to terror as another sleepless night approached. "There was no peace, no rest," she says.
Her husband, to cheer her up, suggested flying lessons. "This,she says now, "to a woman who couldn't decide which shoes to wear."
She considered something more drastic -- killing herself so the rest of the family could get on with life.
Dolores was not just "down" during her periodic depressions. She was in the grip of an illness of the mind that infected all areas of life: She couldn't sleep, couldn't concentrate, couldn't plan or make decisions. She had no appetite. Her sense of self-worth was gone.
"They say you usually get over it, whether you're treated or not, and eventually I would cycle out," she says. "Coming up out of it is like coming up out of a tunnel and into the light."
Depression looms large in her family: Her college-age niece has had an episode; her father had several, which got worse and more frequent as he aged. She also thinks her grandfather was depressed, though in his day there was no name for what was happening to him.
Even now, the title -- used for everything from economic slowdown to romantic letdown -- does not describe it adequately.
"Being sick with depression means you are not able to function in social relationships or in the work situation, says Melvin Prosen, a psychiatrist at Sheppard Pratt Hospital. "You can't get your work done, you can't get up in the morning, you don't enjoy things."
"Patients usually feel ashamed, embarrassed, weak, worthless, ineffective," he says. "They have sleeping and eating disturbances. Things don't taste right or feel right. They lose sexual appetite too. They become isolated, withdrawn. They're unable to get appropriately angry; they turn the anger on themselves.
"Some cases remit [without treatment] in six weeks to three months. Some don't and can progress to suicide."
Remittance is not cure; depression packs a similar wallop the second or third or fourth time around.
"Loss of self-esteem and self-confidence are central themes," says Dr. J. Raymond DePaulo, director of the Center for Affective Disorders at the Johns Hopkins Hospital.
"Patients know, with a little part of their intellect, that they'vcome out of it before, but it moves them to hopelessness and a feeling of worthlessness, and the idea that they'll come out of it again can be discounted."
This is not the sadness of loss, the normal reaction to depressinevents. Author William Styron, whose new book details his disabling depression at age 60, describes it as a feeling of "gloom crowding in on me, a sense of dread and alienation and, above all, a stifling anxiety."
At the height of his success, he was unable to enjoy his triumph, unable to manage his schedule, unable even to hold a conversation. The depression was a pain so intense that he, too, contemplated suicide.
"It's not like the 'blues' people sing about," agrees Hugh Nash, a United Church of Christ minister in Baltimore.
Variously diagnosed as having early Alzheimer's disease, occupational burnout and post-Vietnam stress disorder, he eventually was told he has the double-edged, or bi-polar, form of the disease: He is manic-depressive, prone to periods of boundless energy and enthusiasm that alternate with periods of normalcy and of depression.
Mr. Nash describes the crash that follows an "up" period: "It was like my mind shut off. You can't remember anything; you don't know your own name, or the names of your kids. . . . I really became very dysfunctional, I was suicidal, I even had a plan."
Depression and manic depression, mental illnesses that affect some 10 million Americans, are now recognized as organic diseases, aberrations in the balance of the brain's chemical messengers, called neurotransmitters.
Though triggered sometimes by a disappointment, and sometimes by a long-delayed reaction to loss or disappointment or guilt, depression's patterns from generation to generation and its occurrence in identical twins imply that its roots are in biology rather than biography, says Dr. DePaulo.
Depression is also associated with other recognizably physical disorders, he says. MRI scans have shown areas of damage in the left frontal lobe of the brain of depressed patients with disorders such as Parkinson's disease, Huntington's disease and strokes. Damage elsewhere has not been associated with depression.