Depression

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david

lloyd-hoare

MBACP (Accredited)

Bsc(Hons)

helping you

to help yourself

On this page:

What is Depression? Depression Checklist Understanding Depression

Self Help Are There Different Types of Depression?

How is Depression Treated (including Interpersonal Therapy)

How to Support someone with Depression

Other pages: Suicide Page

What is Depression?

Depression is a "whole-body" illness, involving your body, mood, and thoughts. It affects the way you eat and sleep, the way you feel about yourself, and the way you think about things.

A depressive disorder is not the same as a passing blue mood. It is not a sign of personal weakness or a condition that can be willed or wished away. People with a depressive illness cannot merely "pull themselves together" and get better.

Without treatment, symptoms can last for weeks, months, or years. Appropriate treatment, however, can help most people who suffer from depression.

The symptoms of depression may vary from person to person, and also depend on the severity of the depression. Depression causes changes in thinking, feeling, behaviour, and physical well-being.

Changes in Thinking - You may experience problems with concentration and decision making. Some people report difficulty with short term memory, forgetting things all the time. Negative thoughts and thinking are characteristic of depression. Pessimism, poor self-esteem, excessive guilt, and self-criticism are all common. Some people have self-destructive thoughts during a more serious depression.

Changes in Feelings - You may feel sad for no reason at all. Some people report that they no longer enjoy activities that they once found pleasurable. You might lack motivation, and become more apathetic. You might feel "slowed down" and tired all the time. Sometimes irritability is a problem, and you may have more difficulty controlling your temper. In the extreme, depression is characterized by feelings of helplessness and hopelessness.

Changes in Behaviour - Changes in behaviour during depression are reflective of the negative emotions being experienced. You might act more apathetic, because that's how you feel. Some people do not feel comfortable with other people, so social withdrawal is common. You may experience a dramatic change in appetite, either eating more or less. Because of the chronic sadness, excessive crying is common. Some people complain about everything, and act out their anger with temper outbursts. Sexual desire may disappear, resulting in lack of sexual activity. In the extreme, people may neglect their personal appearance, even neglecting basic hygiene. Needless to say, someone who is this depressed does not do very much, so work productivity and household responsibilities suffer. Some people even have trouble getting out of bed.

Changes in Physical Well-being - We already talked about the negative emotional feelings experienced during depression, but these are coupled with negative physical emotions as well. Chronic fatigue, despite spending more time sleeping, is common. Some people can't sleep, or don't sleep soundly. These individuals lay awake for hours, or awaken many times during the night, and stare at the ceiling. Others sleep many hours, even most of the day, although they still feel tired. Many people lose their appetite, feel slowed down by depression, and complain of many aches and pains. Others are restless, and can't sit still.

Now imagine these symptoms lasting for weeks or even months. Imagine feeling this way almost all of the time. Depression is present if you experience many of these symptoms for at least several weeks. Of course, it's not a good idea to diagnose yourself. If you think that you might be depressed, see a psychologist as soon as possible. A psychologist can assess whether you are depressed, or just under a lot of stress and feeling sad. Remember, depression is treatable. Instead of worrying about whether you are depressed, do something about it. Even if you don't feel like it right now.

Depression Checklist

Answer "yes" or "no" to the following questions. If you are not sure, answer "yes".

Are you often irritable?
Do things seem to get on your nerves?
Do you often feel down?
Do you often have difficulty making decisions, even small ones?
Are you having trouble sleeping, or are you sleeping more than usual?
Do you seem to have less energy than other people?
Do things often seem not worth doing?
Have you lost your appetite, or are you eating more than usual?
Do you more often than not feel life isn't worth living?
Do you frequently wish you would just go to sleep and not wake up?

If you answered "yes" to question 9 or 10, I suggest you speak with a counsellor about your feelings. If you answered "yes" to 3 or more of the first 8 questions, or if you find answering these questions makes you rather anxious you may want to speak with a counsellor. These questions are intended only as a guideline. Your answers to the questions do not, in themselves, indicate either emotional difficulty or emotional health. They are simply a point of information for you to use in making decisions about your life.

Understanding Depression

It is very hard for anyone who has no personal experience of depression to really understand the extent of the problem. This account written by an anonymous sufferer, which appeared in the British Medical Journal, helps put it in perspective:

"A symptom of the bad times is that you think that they will never abate. You convince yourself that you are doomed forever to a state of half life. You awake to a sighing gloom and an inordinate effort of will is required to leave your bed. You know that you should get up to arrest the feeling of despair, but the listlessness which is a characteristic of the condition holds you there, gazing upwards in static stare, musing over the endlessness of the day ahead. Everything is an effort and is carried out in slow motion. The smallest task is a weight on you, minor problems become issues of magnitude. Decisions are deferred and avoided. Simple tasks are shelved. Worst of all is the disintegration of your self-confidence. You fumble in speech and in action. The ringing of a telephone assaults you and you shrink from answering it."

What Causes Depression?

The exact cause of depression remains unclear. The most probable explanation, and the one on which treatment with antidepressant drugs is based, is that it is an imbalance in certain chemical messengers (also called neurotransmitters) in the brain.

The neurotransmitters, of which there are about 30, transfer messages between nerve cells in the brain. Some evidence suggests that depression is caused by a deficiency in two neurotransmitters called noradrenaline and serotonin. Although this does not explain everything that is known about depression, it does at least serve as a useful pharmacological model and is usually referred to as the monoamine hypothesis of depression.

But if depression is caused by an imbalance in these neurotransmitters, what triggers it in the first place ?

Genetic factors

There is growing interest in genetic approaches to understanding a variety of diseases and depression is no exception. Some people certainly seem to be more vulnerable to depression than others and there is growing evidence that some genes could make individuals susceptible to the disease. This would also explain why depression often runs in families. Some studies have shown that people who have relatives with depression have a one in four chance of developing it themselves, compared with only one in 14 for the general population.

Recently scientists at Edinburgh University identified a gene which increases the risk of depression by four times and confers susceptibility to depression in more than 10 per cent of people affected. The gene is known to code a protein involved with the transport of serotonin in the brain which ties in with the pharmacological explanation of depression. But any complete genetic understanding of this illness is a long way and researchers estimate there may be as many as 30 other depressive genes involved.

External triggers

However, in most cases just having these genes is probably not enough to cause depression on its own. Stressful situations can exacerbate this vulnerability. Depression can be triggered by a number of factors such as unemployment, bereavement, social isolation or even a severe physical illness.

Suppression of Emotions

“Many of us spend our whole lives running from feeling with the mistaken belief that you cannot bear the pain. But you have already borne the pain. What you have not done is feel all that you are beyond that pain.”

- Kahlil Gibran

Generally speaking, people who suffer from Depression tend to withhold their feelings.

Research carried out in 2003 at the Dorset Research and Development Support Unit and Institute of Health and Community Studies showed that denying feelings of anger, frustration, sadness, or even excitement can contribute to a state of depression. You may have noticed yourself, or heard others say, that after you let out your angry feelings or have a good cry you feel calmer and more at ease. Expressing feelings can have a distinct physiological effect that results in a reduced level of depression.

There is a lot of evidence to suggest that character and personalities are formed, at least to a greater degree, by the environment in which we were brought up. And that environment of course, is our family, comprising of our parents, grandparents, step-parents and any siblings. I have mentioned above that one major characteristic of those who have depression, is the fear of expressing primary emotions. Most people in this category suppress their feelings, particularly, of anger and sadness.

People often talk about the expression of feelings saying, “I should not feel this way”, or that they are “not being strong”, or that their anger and feelings of grief are “bad, destructive” or “wrong”.

Part of the recovery process, does mean allowing yourself to feel the full extent of your emotions. Appropriate expression of these emotions is healthy. Suppression of your anger and sadness leads to increased feelings of anxiety, depression and helplessness because you are denying the very emotions that will help you work through the experience.

One part of the treatment of depression helps sufferers to be aware of emotions and how to express them appropriately and without fear or shame.

Are there Different Types of Depression?

In the past depression was divided into two types. Reactive or exogenous depression was the term used to describe depression that was caused by an easily identifiable trigger such as loosing your job. Biological or endogenous depression was used for depression that developed out of the blue.

However such a classification has fallen out of favour for a number of reasons. Firstly, it does not seem to matter whether there is an obvious reason for the depression or not - sufferers still respond to the same treatment. And, secondly, there is growing recognition that both internal and external factors play a role in the development of depression in most people. For example, many people get divorced or loose their job without suffering depression so this alone is unlikely to be the sole reason for developing depression.

Today most doctors favour a classification based on the number of symptoms present and the degree to which they interfere with the lives of sufferers. Usually, depression is further divided according to level of overall severity:

Mild depression is often self limiting and may respond to additional support and help. Even so it cannot be dismissed lightly as without treatment it may well develop into moderate depression.

Moderate depression presents with a wider range of symptoms and difficulty in functioning at home or at work.

Severe depression is a serious illness. It causes great and comprehensive distress in all areas of functioning, and is most likely to be associated with suicidal thoughts.

But in addition to these broad categories there are a number of other types of depression recognised :

Depression can be further defined as unipolar or bipolar. In unipolar depression people may suffer from repeated episodes of depression. However, their mood returns to normal at the end of an episode of depression. Bipolar depression, by contrast, is characterised by alternating periods of depression and mania, where the person has an exaggerated sense of well-being which may make them very reckless. This type of illness is also referred to bipolar disorder.

Dysthymia is the name given to an illness in which the symptoms are similar but much milder than those of major depression. It is also characterised by a prolonged course.

Psychotic depression is characterised by psychotic features such as delusions or hallucinations.

Lastly there are a number of specific syndromes. These include seasonal affective disorder (SAD) and post partum depression.

SAD usually occurs only in winter and may be due to a lack of sunlight. One of the most effective treatments appears to be exposure to artificial light

Post partum depression affects mothers usually within six weeks of the birth of a child. A more severe, but rare form, is puerperal psychosis which has symptoms similar to manic depression and often requires admission to hospital.

How is Depression Treated?

Untreated, an episode of depression lasts an average of ten months. Treatment is important not just to resolve the individual episode as soon as possible, but also to prevent future episodes. Many people who have suffered one episode of depression suffer repeated episodes (i.e. recurrences) and studies show that the risk of recurrences increases with the number and severity of previous episodes.

There are three approaches to treatment: the use of psychological (psychotherapy) or talking therapies (counselling), the use of antidepressant drugs, and a combination of both. Many people believe that psychological therapies make more sense than the use of antidepressants - but this ignores the fact that depression is a genuine physical illness. However, the choice of right treatment depends on a variety of factors, such as severity of illness, presenting symptoms, age, etc.

Psychological treatments

The commonest forms of psychotherapy are cognitive behavioural therapy, Interpersonal therapy and psychotherapy.

Cognitive behavioural therapy is a short term ( usually about ten week) structured psychotherapy which aims to help the depressed person replace negative thoughts and attitudes with a more realistic view of themselves and the world about them. You can read more about this type of therapy by viewing the Cognitive behavioural therapy page on this web site.

Psychotherapy focuses more on past and present relationships and examines how they affect the patient's current functioning. You can read more about this type of therapy by viewing the Psychodynamic psychotherapy or Transactional Analysis page on this web site.

Interpersonal therapy (IPT) is a type of treatment for patients with depression which focuses on past and present social roles and interpersonal interactions. Events surrounding interpersonal relationships do not cause depression. But depression occurs within an interpersonal context and affects relationships and the roles of people within those relationships. By addressing interpersonal issues, interpersonal therapy for depression puts emphasis on the way symptoms are related to a person's relationships, including family and peers.

The immediate goals of treatment are rapid symptom reduction and improved social adjustment. The long-term goal is to enable people with depression to make their own needed adjustments. When they can do that, they are better able to cope with and reduce depressive symptoms

IPT does not attempt to delve into inner conflicts resulting from past experiences. Rather it attempts to help the patient find better ways to deal with current problems.

There are two subtypes of IPT. The first type is used for the short-term treatment of a depressive episode. The patient and therapist typically meet weekly for two to four months and treatment ends once the symptoms subside. The second type is maintenance treatment (IPT-M), which is long-term treatment with the goal of preventing or reducing the number of future episodes of depression. IPT-M may consist of monthly sessions over a period of two to three years.

IPT identifies four basic problem areas which contribute to depression. The therapist helps the patient determine which area is the most responsible for his depression and therapy is then directed at helping the patient deal with this problem area.

The four basic problem areas recognized by Interpersonal Therapy are:

Unresolved grief - In normal bereavement, the person usually begins to return to normal functioning within a few months. Unresolved grief is generally grief which is either delayed and experienced long after the loss or distorted grief, in which the person may not feel emotions, but instead experiences other symptoms.

Role disputes - Role disputes occur when the patient and significant people in his life have different expectations about their relationship.

Role transitions - Depression may occur during life transitions when a person's role changes and he doesn't know how to cope with the change.

Interpersonal deficits - This may be an area of focus if the patient has had problems with forming and maintaining good quality relationships.

By focusing on issues from these categories, the therapist can help the person with depression learn how to make the adjustments that are needed to address the interpersonal issue and improve relationships.

Antidepressants

Antidepressant therapies began in 1956 when a drug used in the treatment of tuberculosis was found to elevate mood. Two years later, the antidepressant imipramine was discovered. They provided the first scientifically proven treatments for depression, and demonstrated that depression was amenable to medical intervention.

Now, there is a wide choice of antidepressants available. They are the recognised treatment for all forms of moderate and severe depression regardless of cause. About 70 per cent of patients with depression respond to treatment with antidepressants.

Antidepressants are useful and effective, they are not addictive and do not lose efficacy with continued use.

They can be distinguished most commonly by their safety profile or tolerability, although there are indications that efficacy, especially in severe depression, varies between classes of antidepressants.

What is an Antidepressant?

It is perhaps more difficult to specify exactly what antidepressants do than any other drugs that act on the brain. Antidepressants do not act immediately. The lifting of depressed moods typically takes up to two weeks and can take longer. This is in contrast to other drugs which work on the brain like for example tranquillisers which give you an immediate and usually very obvious effect..

There are two other unique features about antidepressants, which distinguish them from other chemicals which act on the brain.

Antidepressants only seem to affect people who are depressed.

Many drugs which act on the brain have much the same action on people who are unaffected by mental illness or those who have a problem. By contrast, antidepressants only seem to do something to people who are depressed: they don't seem to make someone who is not depressed different in any other way.

The effect of antidepressants does not increase the greater the dose you use.

Dr D Healy in his book ' Psychiatric Drugs Explained' (Mosby, 1997) explains effects of antidepressants using comparison with coffee or alcohol intake. One cup of coffee may be alerting, two cups more so and three cups makes you really wired up. Similarly the more you drink the greater the effect that alcohol has on the brain. But with antidepressants taking a dose above a certain threshold will not increase the antidepressant effect. The only thing which happens is that you are more likely to get side effects. And more worrying some antidepressants can be fatal if taken in relatively small amounts above the recommended maximum dose because of their effects on the heart.

Here are some answers to some common queries about antidepressants.

How do antidepressants work ?

Antidepressants work within the brain to either increase the levels of noradrenaline, serotonin or both. For example, tricyclic antidepressants like amitriptyline increase the levels of both noradrenaline and serotonin in the brain - they consequently have a dual action effect.

However the selective serotonin reuptake inhibitors , SSRIs, work only on the serotonin system. There is a belief among experts that they are not quite as effective as 'dual action' drugs in treating more severe forms of depression.

How quickly will I notice an effect ?

In the first two weeks of treatment most antidepressants do not show a full blown effect on all symptoms of depression. At first you may notice improvement in sleep, or less feelings of anxiety. Improvement in mood is likely to come next. Side effects, however, usually appear from the beginning of treatment. These are generally mild and tend to wear off but if they are intolerable then you should speak to your doctor about them. And rest assured that all these problems halt on stopping the drug - only some have any long term effects.

But even after two weeks, the benefits of antidepressants tend to gradually show up on people. It's like getting over flu: it's hard to tell the difference from day-to-day but you gradually return to normal.

What you should find is a mild increase in appetite and improvement in sleep, followed by a slow increase in energy and return of interest in things,. These effects occur gradually and they may be patchy. In time the feelings of sadness, hopelessness, guilt and suicide gradually subside.

How long will I have to take antidepressants ?

Antidepressants should be taken for at least four months and probably six months after you start to feel well again. Studies show that the risk of relapse is much less likely in these circumstances than if people stop taking them as soon as they are well again.

What are the differences between antidepressants ?

There are several things to consider when a doctor prescribes any drug, that one can roughly divide into drug-related factors (the efficacy, tolerability and safety of the drug) and patient-related factors (age, concomitant diseases and use of other medications, individual sensitivity to side effects, etc.). The doctor (and you) make the decision taking both groups of factors into account. The first mentioned here is the antidepressant's efficacy, that is will it work and how does it compare to other available drugs, and the second is its side effects.

In terms of efficacy most antidepressants are broadly similar. However there are suggestions that drugs which only work on one neurotransmitter in the brain - that is serotonin or noradrenaline but not both - are slightly less effective than drugs which affect both of these systems, in treating more severe forms of depression.

But what about side effects ? Antidepressants differ widely in the side effects they produce. Here is a list of the major classes of antidepressants:

Tricyclic antidepressants e.g. amitriptyline and clomipramine
Monoamine oxidase inhibitors (MAOIs) e.g. phenelzine
Selective serotonin reuptake inhibitors e.g. fluoxetine, paroxetine, sertraline, citalopram, fluvoxamine.
Noradrenergic and Specific Serotonergic Antidepressants (NaSSA)

Medication Page

Click on the above links for more information on medication.

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Self-help with Depression -Coping Statements

Learning how to manage your feelings and behaviours takes work and practice. However, one simple way to get started is to develop "coping statements" to counter upsetting thoughts. Coping statements are somewhat like affirmations, but they are not necessarily positive ideas. Rather, they are realistic or reality based. Coping statements are usually challenges to specific upsetting thoughts, although you can use them any time.

The idea here is to stop yourself whenever you feel upset, like anxious, worried, depressed, angry, guilty, ashamed, frustrated and so on. You can also use undesired urges or behaviour, like procrastination, smoking, drinking or drugging as a cue to start the process. Catch yourself, then try to observe what thoughts are running through your mind. Take a sheet of paper and divide it in half vertically. On the left side of the sheet, write out whatever thoughts you have observed.

Once you have identified the offending thoughts, just try changing them. As you get into this more, you will probably want to learn how to dispute or evaluate your thoughts on several levels, but the simple form of this exercise is to change the thoughts in any way that helps you feel or behave differently. Keep trying different alternatives until you find one that works for you. Here are some examples to help you get started:

Upsetting Thoughts v Realistic Alternatives

Hopefully, you get the idea. Try it! I think you will like the results. Not only will you feel better, but you will probably find that you have a lot more energy to put into solving the real problems in your life, not just wasting energy on getting needlessly upset..

How Can You Support Someone with Depression?

They may fervently believe that nobody can help and life is pointless. This lack of hope is a common symptom. But there is point to their life and there are plenty of things that you can say and do to help. These are suggestions that I hope will give you solid ideas on how to support someone with depression.

1. Understand Depression

Learn all that you can about depression. The better you grasp the illness, the more effective you will be in giving your care and support. It will help you to understand why the person behaves the way they do, and better equip you to respond appropriately.

2. Appropriate Depression Treatment

This is such a far-reaching, wide-ranging topic that I would be foolish to give advice. It will be helpful for you to explore the treatment options available in your area and suggest to the person that they need professional help. It might be helpful for them if you go along to the first or subsequent appointments.

If he or she won’t admit their illness then explain why you are concerned and perhaps provide them with some helpful written information to think over.

3. Emotional Support

Your partner or friend needs patience, care and understanding. They have a real illness, and just like someone with cancer they can’t just “snap out of it”. If they could, they would. Saying things that show ignorance about how to deal with depression is counterproductive and will reinforce their negative thinking.

There are many ways to hurt someone with depression, without even trying very hard. These days the old "just snap out of it" saying lacks imagination. There are many ways to give some unsolicited advice.

Here are the some unhelpful sayings:

“You don’t like feeling that way? So change it!”
“Life isn’t meant to be easy.”
“This is what life is like. Get used to it.”
“Pull yourself together.”
“Who said that life is fair?”
“You just have to get on with things.”
“At least it’s not that bad.”
“Stop feeling sorry for yourself.”
“You have so many things. What do you have to feel down about?”
“You just need to cheer up.”
“Quit trying to be a martyr.”
“Stop taking all those medicines.”
“I know how you feel. I’ve been depressed for whole days at a time.”

These are my favourite unhelpful and hurtful sayings:

“What you need is a good kick up the backside.”
“Go out and buy yourself some clothes. That will pick you up.”
“Are you sure you don’t have a mental problem?”
“How about I cook you a good meal. That will make things better.”
“Have you tried acupuncture?”
“Get a job!”

And the all time winner:

“Why don’t you try not being depressed.”

Nothing cuts deeper to someone with depression, than when their serious condition is trivialised by another who doesn’t understand it

The best way to communicate is to empathize, listen more than talk, and ask questions like “How can I support you?” or “How can I help?”

4. Separate the Illness and the Person

The depression and the person suffering with depression are not the same thing, so keep them separate. When they express pessimism, anger, frustration, or sadness, it is the illness talking not the person. If you separate the two you will find it easier to cope emotionally. It will help you to be a more effective caregiver.

5. Listen Non-Judgmentally

Don’t try to talk a depressed person out of their feelings, no matter how irrational they sound. This is likely to compound the problem. It is better to remain neutral and say something like “You are obviously really suffering with this. What can I do to help you feel better?” Keep your suggestions, solutions and advice for another time.

6. Make a Plan for Coping with Depression

Help the person to make a plan for how to cope with depression. Identify things that trigger or worsen the depression and things that make it better. Think through and list the ideas formally on paper. Help them to put this plan into action. Some positive, helpful things to include are getting to bed early, having adequate sleep, exercising regularly, drinking plenty of water and eating healthy foods.

7. Look After Yourself

As a caregiver you are likely to be under stress. You need to care for yourself by taking time out and recharging your batteries. Find other friends or relatives who you can talk to and rely on at a pinch. Sometimes you will need a sounding-board to keep things in perspective. Make sure you continue to live your own life as well, and spend time doing things you enjoy.

There are services that provide education and support for caregivers. Through information sessions and support groups, you can talk to people who are in a similar position.

8. Organise their Medications

If your partner or friend is taking depression medication then it is crucial for them to follow their prescription. Too many people go on and off their anti-depressants depending on how they feel. This all but eliminates their effectiveness.

I take medicine at night without any problems, but if it wasn’t for my wife handing the pills to me I would never take them in the mornings. She also fills my scripts and tells me when to go to the doctor for more. It’s not laziness; it’s just the nature of depression. More than once I have spent hours in bed staring at my pills, but not had the mental energy to actually take them. If your partner or friend is not taking their depression medication as prescribed, try to find out how you can help.

9. Depression Support Groups

Introduce the idea of joining a depression support group. This will give them an outlet for discussing their problems and receiving input, and help them to discover that there are other (normal) people experiencing similar problems. There are depression support groups everywhere. Make sure that you find one that is positive and focused on recovery. Inward looking, pessimistic groups can be unhelpful.

10. Get Out and About

One of the most therapeutic things that a depressed person can do is step out the front door. Natural light is very beneficial, especially early in the day. Exercise also has proven benefits. Something as simple as taking a walk or gardening should lift the person’s mood. Anything low-key that involves going out can also help; seeing a movie, meeting friends, or going out to eat, to name just a few ideas.

11. Help with Daily Tasks

When your body is heavy and your mind is dark, there is nothing harder than the burdens of everyday life. Looking after something that seems minor to you may be invaluable in helping a person with depression. Ease their burden by helping with the daily load – running errands, doing the shopping, cooking, taking the kids out for a couple of hours. You may be surprised to find that helping with a very simple chore could relieve them of a lot of stress.

12. Spend Normal Time Together

Just spending time with the person lets them know that you care and want to understand their problems. Enjoy the reasons for being their companion in the first place. It’s important that they live as normal a life as possible. Help them to do this by carrying on your relationship with them in a normal fashion. Don’t let everything get dark and serious. Find some positive things and try to enjoy them together.

The points above are very general by necessity. I realise that they don’t fit all circumstances, but I hope they give you some ideas on how to support someone with depression.