CASE STUDY : Depression

Depression is a common experience. We have all felt 'depressed' about a friend's cold shoulder, misunderstandings in our marriage, tussles with teenage children - sometimes we feel 'down' for no reason at all.

However, depression can become an illness when:

* The mood state is severe;
* It lasts for 2 weeks or more; and
* It interferes with our ability to function at home or at work.

Signs of a depressed mood include:

Lowered self-esteem (or self-worth)
Change in sleep patterns, that is, insomnia or broken sleep
Changes in appetite or weight
Less ability to control emotions such as pessimism, anger, guilt, irritability and anxiety
Varying emotions throughout the day, for example, feeling worse in the morning and better as the day progresses
Reduced capacity to experience pleasure: you can't enjoy what's happening now, nor look forward to anything with pleasure. Hobbies and interests drop off.
Reduced pain tolerance: you are less able to tolerate aches and pains and may have a host of new ailments
Changed sex drive: absent or reduced
Poor concentration and memory: some people are so impaired that they think that they are going demented
Reduced motivation: it doesn't seem worth the effort to do anything, things seem meaningless
Lowered energy levels.

If you have such feelings and they persist for most of every day for two weeks or longer, and interfere with your ability to manage at home and at work, then you might benefit from getting an assessment by a skilled professional.

Having one or other of these features, by themselves, is unlikely to indicate depression, however there could be other causes which may warrant medical assessment.

If you are feeling suicidal it is very important to seek immediate help, preferably by a mental health practitioner.

Frequently Answered Queries :
What are the signs of depression?
How depressed should I be before I seek help?
What should I do if I'm feeling (or someone close to me is feeling) suicidal?
Am I always going to feel like this?
How long does depression last?
How is depression treated?
Where can I get help for depression?
How should I behave with someone who is depressed?

1. What are the signs of depression?

The following are a list of the features that may be experienced by someone with depression.

* Lowered self-esteem
* Change in sleep patterns
* Change in mood control
* Varying emotions throughout the day
* Change in appetite and weight
* Reduced ability to enjoy things
* Reduced ability to tolerate pain
* Reduced sex drive
* Suicidal thoughts
* Impaired concentration and memory
* Loss of motivation and drive
* Increase in fatigue
* Change in movement
* Being out of touch with reality.

Note that, having one or other of these features, by themselves, is unlikely to indicate that someone is clinically depressed. Also, having these features for only a short period (of less than two weeks) is unlikely to indicate clinical depression. It's also important to know that many of the above features could be caused by or related to other things, such as a physical illness, the effects of medications, or stress. Help in coming to such decisions should be assisted by a proper assessment by a trained professional.

2. How depressed should I be before I seek help?
Everybody feels down or sad at times. But it's important to be able to recognise when depression has become more than a temporary thing, and when to seek help.

As a general rule of thumb, if your feelings of depression persist for most of every day for two weeks or longer, and interfere with your ability to manage at home and at work or school, then a depression of such intensity and duration may require treatment, and should certainly benefit from assessment by a skilled professional.

What should I do if I'm feeling (or someone close to me is feeling) suicidal?
See the list of emergency contact numbers (and add the numbers of your General Practitioner and your local Community Mental Health Service) and keep a copy handy somewhere. Don't hesitate to call one of them if in need of help.

Recognise that having suicidal thoughts is one of the features of depression, and seek help, either from your General Practitioner or another mental health professional such as a psychologist or a counsellor. Make sure you tell them you have been having suicidal thoughts.

If you have already received treatment for depression, and you are having suicidal thoughts, contact the person who has been giving you the treatment, or a close friend who you trust, and tell them you are feeling suicidal.

If someone close to you is suicidal or unsafe, talk to them about it and encourage them to seek help. Help the person to develop an action plan, involving him or her and trusted close friends or family members, to keep him or her safe in times of emergency

Take away risks (e.g. remove guns or other dangerous weapons and hold the keys of the car if the depressed person is angry, out of control and wanting to drive off into the night).

Am I always going to feel like this?
This is a common fear. It's important to know that depression can be successfully treated and that you will feel better in time and with the right treatment.

5. How long does depression last
Sometimes depression goes away of its own accord, but, depending on the nature and type of the depression, it may take many months and possibly considerable suffering and disruption if left untreated. Allow yourself to seek help in the same way you might if you had a physical illness.

6. How is depression treated?
There are a large number of different treatments for depression. At the Black Dog Institute we believe that different types of depression respond best to different treatments and it is therefore important that a thorough and thoughtful assessment be carried out before any treatment is prescribed.

Treatments can fall into the following categories:

Physical treatments, comprising :
Drug treatments, of which there are three main groups: antidepressants, tranquillisers, and mood stabilizers.

Electroconvulsive therapy (ECT) - a physical therapy that may be relevant in a minority of cases of psychotic depression, severe melancholia or life-threatening mania.

transcranial magnetic stimulation - a treatment that is still under development, but which involves holding a coil near to a patient's head and creating a magnetic field to stimulate relevant parts of the brain.

Psychological treatments, the most common ones being:

Cognitive Behaviour Therapy - a form of therapy that aims to show people how their thinking affects their mood and to teach them to think in a less negative (and more 'realistic') way about life and themselves.

Interpersonal Therapy - a therapy that aims to help people understand how social functioning (work, relationships and social roles) and personality operate in their lives to affect their mood.

Psychotherapy - an extended treatment aimed at exploring aspects of the person's past in great depth to identify links to the current depression.

Counselling - a broad set of approaches and goals that provide problem solving and learning skills to cope with difficult life circumstances.

7. Where can I get help for depression?

A good first place to start in getting help is to visit your local General Practitioner. Let him or her know if you think you might have depression. Your General Practitioner will either conduct an assessment of you to find out whether you have depression, or refer you to someone else, such as a psychiatrist or a psychologist.

Depending on the nature of your depression, your General Practitioner may recommend some psychological intervention, such as cognitive behaviour therapy or interpersonal therapy, and might prescribe antidepressant medication to relieve some of the symptoms of depression.

Because depression is a common experience these days, many General Practitioners are used to dealing with depression and other mental health problems. Some General Practitioners take a special interest in mental health issues and undergo additional training in the area. If you don't feel comfortable talking to your own doctor, find another one with whom you do feel comfortable. It is important that you feel comfortable talking about how you are feeling with your doctor so they have as much information to help you as possible.

If you are having trouble tracking down such a General Practitioner, you could telephone general practices in your area to find out whether any doctors in that practice have a particularly strong interest in mental health and, if so, whether they are taking on new patients.

8. How should I behave with someone who is depressed?
Someone with a depressive illness is like anyone with an illness - they require our care. You can provide better care if you are able to:

Understand something about the illness

Understand what the treatment is, why it is being given, and how long the person is expected to take to recover.

An important part of caring is to help the treatment process:

If medication is prescribed encourage the person to persist with treatment (especially when there are side effects)

Counselling or psychotherapy often results in the depressed person 'thinking over' their life and relationships. While this can be difficult for all concerned, you should not try and steer the person away from these issues.

A resolving depression sometimes sees strong emotions released which may be hard on the carer. The first step in dealing with these fairly is to sort out which emotions really refer to the carer and which refer to other people or to the person themselves.

Treatment has a positive time as well - when the person starts to re-engage with the good things in life and carers can have their needs met as well.

Don't forget that as a carer you too are likely to be under stress. Depression and hopelessness have a way of affecting the people around them. Therapy can release difficult thoughts and emotions in carers too. So part of caring is to care for your own self - preventing physical run-down and dealing with the thoughts and emotions within yourself.

Physical Treatment :

The main physical treatments for depression comprise

Drug treatments

Electroconvulsive therapy

A third physical treatment with as yet narrow application is

Transcranial magnetic stimulation.

Drug Treatments
There are three groups of drugs most likely to be used for depression:



Anti-manic drugs or mood stabilisers

There is a large number of antidepressants - they have a role in many types of depression and vary in their effectiveness across the more biological depressive conditions.

Selective Serotonin Reuptake Inhibitors (SSRIs), Tricyclics (TCAs) and Irreversible Monoamine Oxidase Inhibitors (MAOIs) are three common classes of antidepressants. They each work in different ways and have different applications.

We believe that they are not, however, equally effective and that it is necessary to find the right antidepressant for each person.

If the first antidepressant does not work, it is sensible to move to a different kind of antidepressant. For the biological depressive disorders, more broad action antidepressants are usually more effective.

A well-informed health provider should be able to use their assessment of the type of depression, its likely causes and their understanding of the person to identify the medication most likely to benefit.

Finally, being able to decide not to use medication is important too.

These medications are usually called 'minor' or 'major' tranquillisers.

Minor tranquillisers (typically benzodiazepines) are not helpful in depression; they are addictive and can make the depression worse.

Major tranquillisers are very useful in people with a psychotic depression and in melancholia where the person is not being helped by other medications.

'Anti-manic' drugs or 'mood stabilisers'
These drugs are of great importance in bipolar disorder.

Their use in treating mania makes them 'anti-manic', while their ability to reduce the severity and frequency of mood swings makes them 'mood stabilisers'.Lithium, valproate and carbamazepine are the most common.

It is important to remember that the anti-depressants and mood stabilisers are often necessary both to treat the depression that is occurring now, and to make a relapse in the future less likely. So people sometimes need to continue taking medication for some time after they are better.

Electroconvulsive Therapy (ECT)
Because of its controversial past many people feel the need to think carefully before having ECT or allowing it to be given to relatives.

Clinicians at the Institute firmly believe that ECT has a small but important role in treatment, particularly in cases of

Psychotic depression

Severe melancholia where there is a high risk of suicide or the patient is too ill to eat, drink or take medications

Life-threatening mania

Severe post-natal depression.

While there are some short-term side-effects, ECT is a relatively safe and, because an anaesthetic is used, not too unpleasant.

Transcranial magnetic stimulation (TMS)

A possible alternative to ECT is transcranial magnetic stimulation (TMS).

Transcranial magnetic stimulation is a procedure used by neurologists, both as a treatment and as diagnostic procedure. A coil is held next to the patient's head and a magnetic field created to stimulate relevant parts of the brain. Unlike ECT, there is no need for a general anaesthetic nor is a convulsion induced.

In our view, the evidence in favour of this treatment is not yet in, but it is a major area of research at the Institute and elsewhere. If TMS is shown to be as effective as ECT this would be a distinct advance in the treatment of many mood disorders. No clear evidence about its utility is expected for a number of years.

Psychological Treatment

There are a wide range of psychological treatments for depression.
Some of the main ones are:

* Cognitive Behavior Therapy (CBT)
* Interpersonal Therapy (IPT)
* Psychotherapies
* Counseling
* Narrative Therapy

CBT, IPT, psychotherapy and counselling all provide either an alternative to medication or work alongside medication. As always, a thorough assessment of the person is needed in order to decide on the best set of approaches.

Cognitive Behaviour Therapy (CBT)
People suffering from depression - particularly 'non-melancholic depression' - will often have an ongoing negative view about themselves and the world around them. This negative way of thinking is often not confined to depression, but is an ongoing part of how the person thinks about life. Many or all of their experiences are distorted through a negative filter and their thinking patterns become so entrenched that they don't even notice the errors of judgement caused by thinking irrationally.

Cognitive behaviour therapy aims to show people how their thinking affects their mood and to teach them to think in a less negative way about life and themselves. It is based on the understanding that thinking negatively is a habit, and, like any other bad habit, it can be broken.

CBT is conducted by trained therapists either in one-on-one therapy sessions or in small groups. People are trained to look logically at the evidence for their negative thoughts, and to adjust the way they view the world around them. The therapist will provide 'homework' for between sessions. Between 6-10 sessions can be required but the number will vary from person to person.

CBT can be very beneficial for some individuals who have depression but there will be others for whom it is irrelevant.

Interpersonal Therapy (IPT)
The causes of depression, or our vulnerabilities to developing depression, can often be traced to aspects of social functioning (work, relationships, social roles) and personality . Therefore, the underlying assumption with interpersonal therapy is that depression and interpersonal problems are interrelated.
The goal of interpersonal therapy is to help the person understand how these factors are operating in the person's current life situation to lead them to become depressed and put them at risk to future depression.
The therapy occurs in three main phases:
* An evaluation of the patient's history
* An exploration of the patient's interpersonal problem area and a contract for treatment
* Recognition and consolidation by the patient of what has been learnt and developing ways of identifying and countering depressive symptoms in the future.
* Usually 12-16 sessions of IPT will be required.

Psychotherapies :
Psychotherapy is an extended treatment (months to years) in which a relationship is built up between the therapist and the patient. The relationship is then used to explore aspects of the person's past in great depth and to show how these have led to the current depression. Understanding this link between past and present - insight - is thought to resolve the depression and make the person less vulnerable to becoming depressed again.

Counselling :
Counselling encompasses a broad set of approaches and goals that are essentially aimed at helping an individual with problem solving - solving long-standing problems in the family or at work; or solving sudden major problems (crisis counselling).

Narrative Therapy :

Narrative Therapy is a form of counselling based on understanding the 'stories' that people use to describe their lives. The therapist listens to how people describe their problems as stories and helps the person to consider how the stories may restrict them from overcoming their present difficulties. It sees problems as being separate from people and assists the individual to recognise the range of skills, beliefs and abilities that they already have (but may not recognise) and that they can apply to the problems in their lives.

Narrative Therapy differs from many therapies in that it puts a major emphasis on identifying people's strengths, particularly as they have mastered situations in the past and therefore seeks to build on their resilience rather than focus on their negatives.

Treatments :

A large number of different treatments are available for depression.
New treatments (particularly medications) appear regularly. Continuing research means that the evidence for how well a treatment works is always changing too. We have chosen to give only a brief summary of treatments and instead direct you to other sites which provide more comprehensive details.

Key points about treatments for depression :
We believe that different types of depression respond best to different sorts of treatments (see below).
* It's important that a thorough and thoughtful assessment be carried out before any treatment is prescribed.
* Treatments for depression include physical and psychological treatments.
* Depression can sometimes go away of its own accord but, left untreated, it may last for many months. Allow yourself to seek help.
* Depending on the nature of your depression, self-help and alternate therapies can also be helpful, either alone or in conjunction with physical and psychological treatments.

Different types of depression need to be treated differently & there are different types of depression, falling into the following three principal classes:

Melancholic depression
Non-melancholic depression
Psychotic depression.

Those types of depression that are more biological in their origins (melancholic depression and psychotic melancholia) are more likely to need physical treatments and less likely to be resolved with psychological treatments alone.

We believe non-melancholic depression can be treated equally effectively with physical treatments (antidepressants) or with psychological treatments.

Types of Depression :
We believe that there are three broadly different types of depression:
* Melancholic depression
* Non-melancholic depression
* Psychotic depression
A possible fourth type of depression is Atypical depression.

Why is this important? We believe that, as with any illness, the person suffering from it can’t be properly treated unless the specifics of their illness are understood.

We therefore believe that people who are depressed should receive a sophisticated assessment identifying their particular type of depression and its broad causes, whether biological, psychological or other.

Treatments should be selected according to the specific type of depression experienced by an individual, and its causes.

A description of the different types of depression follows.

Melancholic depression :
Melancholic depression is the classic form of biological depression. Its defining features are:a more severe depression than is the case with non-melancholic depression psychomotor disturbance
Melancholic depression is a relatively uncommon type of depression. It affects only 1-2 per cent of Western populations. The numbers affected are roughly the same for men and women.

Melancholic depression has a low spontaneous remission rate. It responds best to physical treatments (for example antidepressant drugs) and only minimally (at best) to non-physical treatments such as counseling or psychotherapy.

Non-melancholic depression :
‘Non-melancholic depression’ essentially means that the depression is not melancholic, or, put simply, not primarily biological. Instead, it has to do with psychological causes, and is very often linked to stressful events in a person’s life, alone, or in conjunction with the individual’s personality style.

Non-melancholic depression is the most common of the three types of depression. It affects one in four women and one in six men in the Western world over their lifetime.

Non-melancholic depression can be hard to accurately diagnose because it lacks the defining characteristics of the other 2 depressive types (viz psychomotor disturbance or psychotic features). Also in contrast to the other 2 depressive types, people with non-melancholic depression can usually be cheered up to some degree.

People with non-melancholic depression experience a depressed mood more than two weeks social impairment (for example, difficulty in dealing with work or relationships).
In contrast to the other types of depression, non-melancholic depression has a high rate of spontaneous remission. This is because it is often linked to stressful events in a person’s life, which, when resolved, tend to see the depression also lifting.

Non-melancholic depression responds well to different sorts of treatments (such as psychotherapies, antidepressants and counselling), but the treatment selected should respect the cause (e.g. stress, personality style).

Psychotic depression :
Psychotic depression is a less common type of depression than either melancholic or non-melancholic depression.
The defining features of psychotic depression are:

* An even more severely depressed mood than is the case with either melancholic or non-melancholic depression

* more severe psychomotor disturbance than is the case with melancholic depression

psychotic symptoms (either delusions or hallucinations, with delusions being more common) and over-valued guilt ruminations.

Psychotic depression has a very low spontaneous remission rate. It responds only to physical treatments (such as antidepressant drugs).

Atypical depression :
Atypical depression is a name that has been given to expressions of depression that contrast with the usual characteristics of non-melancholic depression. For example, rather than experiencing appetite loss the person instead experiences appetite increase; and sleepiness rather than insomnia. Someone with atypical depression is also likely to have a personality style of interpersonal hypersensitivity (that is, expecting that others will not like or approve of them).

The features of atypical depression include:

* The individual can be cheered up by pleasant events

* Significant weight gain or increase in appetite (especially to comfort foods)

* Excessive sleeping (hypersomnia)

* Arms and legs feeling heavy and leaden

* A long-standing sensitivity to interpersonal rejection —the individual is quick to feel that others are rejecting of them.

Causes of depression :
While researchers often talk about ‘finding the cause’ of some disease or disorder this often obscures the fact that only part of the story is known.

Some causes are pretty straightforward. We know that a broken leg is usually the result of some kind of pressure or strain being applied. Moreover, if you have a broken leg you typically know when it happened (leg was fine yesterday, today it is broken) and how it happened (this morning you went skiing).

Things are not so simple with depression. We have good ideas about what some of the ‘pressures or strains’ that result in depression are – but they are not all agreed upon and there might be others.

For any one person there could be many ‘pressures’ in their life. It is often unclear when the depression started – much of the time it gradually has an effect.

We can see another complication by going back to the broken leg example. Some people suffer from osteoporosis which makes their bones more fragile (more vulnerable). If you only had a minor accident when you went skiing, your osteoporosis was probably as much the cause of your broken leg, since it made your leg more vulnerable to the effects of pressure. If you have a major accident, however, the leg will probably break, osteoporosis or not.

In other words, the causes of depression are some mixture of ‘pressure’ (mild to severe) combined with a vulnerability to depression (as a sort of ‘psychological osteoporosis’) which too can range from mild to severe.

As noted earlier, for each ‘type’ of depression, differing ‘mixtures of causes’ have differential relevance. Thus, for psychotic or melancholic depression physical and biological factors are generally more relevant. By contrast, for non-melancholic depression, the role of personality (osteoporosis) and life-event stressors (accident) are generally far more relevant.

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