Understanding Depression
By Maria Prendergast-March 2008
It can be confusing for the non- medical person to wade through the masses of information relating to depression. It is important to remember that medicine is not an exact science – while much is known about depression there is much more to be discovered and understood. My latest book Understanding Depression was written for the non-medical person who wants to know more about this pervasive and destructive illness. Though depression seems to be constantly in the news media, be it high profile celebrities talking about their depression or reports of new drugs or other breakthroughs, our society as a whole is not well educated or particularly understanding when it comes to any form of mental illness.
One in five Australians will experience clinical depression at least once in their life and as I learnt through my research and interviews, depression is not only devastating for patients but for their family, friends and work associates. It is a major health issue in Australia where it is currently estimated that over six million working days are lost to depression. People of all ages can experience depression with children as young as five have been diagnosed. It is also one of the most common mental health disorders in older people.
The more we know about an illness the better equipped we are to deal with it, either as a patient, family member, friend or work mate. Depression is not as a few people still seem to believe, a character flaw or a sign of weakness. Depression is a genuine illness and should be recognised as such. It is an illness that is not easy to define and so can be hard to diagnose. People’s experiences and symptoms can be extremely diverse. Untreated long- term depression can be a fatal disease and any form of depression can make life very difficult. It is not only severe depression that can make life a miserable experience and disrupt a person’s normal existence.
Individuals suffering from any type of depression need the help and support of an enlightened society rather than have their suffering increased by misunderstanding, stigma and ignorance. It is really sad that in the twenty- first century the subject of mental illness still attracts prejudice and ignorance. Unfortunately many people only superficially accept depression as a genuine illness and even more unfortunately, an underlying stigma is still attached to depression.
While some people will forever deny their depressive state others readily acknowledge their condition. Generally though it seems that accepting mental imperfections is harder than accepting physical illness. Most depression sufferers I spoke with were angered and upset at the initial responses of people when depression was mentioned. Some of the depression sufferers I spoke with reported losing their jobs and incurring hostility from family and friends after being diagnosed with their illness. It seems that there are still members of the community who find mental illness in another person very hard to deal with. They save their compassion and support for the physically afflicted person.
The word depression is often used inaccurately. People say they are depressed when what they mean is that they are upset, angry, frustrated or just experiencing a normal lowering of mood. Mild, short lasting mood swings are a completely healthy part of the human condition. Feelings of sadness ranging from ‘bit flat to extreme grief ' is not to be confused with severe depression. It is when a mood outlasts its context that it can become a serious threat to emotional health and functioning.
For my book I interviewed many depression sufferers and others who either live or work with a person suffering from depression. I am in awe of the courage and bravery shown by many of these individuals who spoke openly and in great detail about depression and how it affects their lives. Most human beings have times when they have a depressed mood. This is quite normal and does not generally interfere with everyday life in a significant way. These normal depressed moods can last from a few minutes to a few weeks and can be accompanied by feelings of irritability, negativity, pessimism, fatigue and lack of self-worth. A normal depressed mood is not usually all consuming, though it can be very unpleasant, but it does not cause the problems and disruption associated with clinical depression.
Clinical depression is a form of mental illness characterised by longer than normal and excessive disturbances of mood. These mood disturbances are frequently accompanied by a range of other symptoms and can impact directly on a person’s life and their ability to cope with life events. Clinical depression can cause significant distress and impairment in social, occupational and other important areas of human functioning. Regardless of what type of depression a person has, their suffering is very real and can cause them and their families great stress and anxiety.
Anthony Storr writes about ‘normal people’ as opposed to ‘depressed people’ in his book Churchill’s Black Dog. I think that this sort of comment is unhelpful because it infers that people with depression are different from the rest of the human race. No one really wants to be labelled because they suffer from a certain type of physical illness. We are all a lot more than our illness, be it ‘an asthmatic, a diabetic or a depressive.’ People with depression have the misfortune of suffering from an illness that is still surrounded by misconceptions and myths. Life is made harder for a depressed person if they feel they will never be ‘normal’ again.
It can be particularly galling for a person suffering from depression to observe another person surviving a really hard time without becoming depressed or over- stressed. This reinforces the view that depression is some sort of character flaw. Many people suffering depression develop feelings of shame and guilt.
The following is a quote from a Sydney GP whom I interviewed. This doctor is bemused at the number of patients coming into his surgery who he believes are suffering from depression.
Is it the result of a terrible malaise in our society? So many people seem unhappy and discontented in their life. You read about people working longer and longer hours and not having time to nurture personal relationships or engage in any leisure activities. Humans are not machines. We need to have a balanced life if we are to be mentally and physically well. I am really freaked by the increasing number of people coming into my surgery suffering from some degree of depression. And let me add that I work in an affluent suburb in Sydney. Money worries are not the cause of what is making so many of my patients depressed. Sometimes I really don’t know how to respond, particularly when so many obviously need help but are not prepared to admit the problem. I know a lot of my patient’s lie to me, even though they know they need help. It’s a very, very difficult situation.”
Diagnosing Depression
Depression often runs in families and some people are genetically predisposed towards depression. Then again, an individual can suffer depression and have no other relatives with the illness.Statistics available indicate that more women than men suffer from depression and anxiety. However some doctors I spoke with believe that what can be seen as a gender imbalance may be attributable to the fact that more women than men seek help for their illness.
There is a big difference between sadness, despair and depression –an accurate diagnosis of what is really going on allows the right decisions to be made regarding the most appropriate treatment. Unfortunately only about 20% of cases of clinical depression are correctly diagnosed, one reason being that depression can masquerade as a variety of physical ailments such as aches and pains, lack of energy or bad sleep patterns. When a patient complains about a physical condition the doctor generally treats it as such, and the underlying depression remains undetected.
Some people simply refuse to acknowledge they are depressed, others don’t know they are depressed. Many people realise that they feel awful emotionally and that life is increasingly hard but accept this state as an inevitable part of their existence. This very passivity can in itself be a sign of depression.
The line between normal and clinical depression is crossed when the feelings associated with a low mood increase in intensity, when they last for a longer period than normal and when a person’s ability to function is impaired.
These disturbed mood feelings and the accompanying symptoms have usually been present in most people for at least two weeks before clinical depression is diagnosed. It may be a transient mood fluctuation if it is present for less than this time and the person could well return to normal without any medical intervention.
One common characteristic of people with depression is an accompanying lack of self-esteem. Those with depression find that maintaining a sense of self-worth is just about impossible. Feelings of guilt and shame are also common. Other common symptoms of depression are:
- Reduced interest and enjoyment in activities and events. Lack of ability to experience any pleasure
- Insomnia or disturbed sleep patterns. Or hypersomnia (sleeping too much)
- Persistent pessimistic and negative thoughts
- Marked changes in mood control such as increased levels of irritability, anger or anxiety
- Lack of motivation
- Lack of energy and feelings of fatigue
- Impaired concentration and memory
- Reduced sex drive
- Changes in appetite and weight fluctuations - Some people may gain weight
- Recurrent thoughts of death or suicide
Before a diagnosis of depression is confirmed it should be established that the symptoms are not being caused by another illness or are not a reaction to a major life crisis such as the death of a spouse. Even people suffering deep grief do not automatically become depressed, though some of the symptoms can be the same. Others factors such as drug and alcohol consumption, and even personality traits can affect such things as mood changes, anxiety levels and sleep patterns. If you are experiencing some of these symptoms it does not necessarily mean that you have depression but you should consult your doctor and explain how you are feeling.
Types of Depression
Most health professionals now accept that depression is not a single, distinct medical condition. There are a number depressive disorder sub-types and they can vary from severe to less severe to moderate or mild. They also differ in the length of time over which they affect a person. Until comparatively recently depression was seen as a disorder that was differentiated only in its degree of severity. Quite large numbers of mental health experts still hold this view and consequently treat their patients for a single disorder rather than trying to be more specific in their diagnosis.
There continues to be considerable debate amongst the medical and scientific community as to how clinical depression and its various forms are best classified. Even within the broad classification of ‘major depression’ and ‘minor depression’ there is a bewildering array of classifications, categories and sub-types. Trying to understand all the sub-types is further complicated by the fact that many symptoms are similar, overlap and merge and some people may be suffering concurrently from more than one type of depressive disorder.
It is beyond the scope of this article to go into the clinical descriptions of all the varying sub-types of depression and it is not necessary to know them all to have a good understanding of depression overall. However if you are experiencing depression it is worthwhile to bring up the question of what sub-type type of depression you may be suffering from with your doctor.
I must stress that all depressive states have the ability to impact on a person’s life and the lives of the people around them. Depression of any sort is something that should never be accepted as a state of being that need be born with stoicism and acceptance. Depression in any of its various forms is not an illness that the person affected can afford to be sanguine about, for even cases of mild depression can last for long periods of time if left untreated and can have very devastating effects on the person.
The long held belief that depression is either ‘reactive’ or ‘endogenous’ in origin is losing support. It is now more widely accepted that both environment and an individual’s genetic history play a part.
Sometimes a person suffering from bereavement or recovering from a major crisis can plummet from normal grief or anxiety into depression. Some people can have trouble emotionally adjusting to distressing life events and their low moods can continue unabated. They are simply unable to shake off the deep blues and regain normal function. Those who develop depression following an initial normal response to difficult or emotionally upsetting circumstances are described as suffering from an adjustment disorder with a depressed mood.
Treatments for Depression
It is very hard for some people suffering from depression to acknowledge they are ill and need help. As one country GP told me, men in particular are reluctant to seek medical help for anything, and are particularly reluctant to discuss emotional problems. ‘It is vitally important that people do not let their depression go undiagnosed and untreated. I want to stress that most depression can be successfully treated. I despair when I hear patients confess they feel ashamed about having depression. This misconception about depression being a sign of failure makes me very upset. The sooner depression is treated in an individual the better the response. If you think you have depression, please seek help.’
It is important that everyone with depression be assessed and treated on an individual basis. There is however, a vigorous and ongoing debate among medical and allied health professionals about the preferred modes of treatments. Some doctors and scientists will argue that there is not enough empirical evidence to recommend any form of treatment as the optimal treatment. However, the broad consensus is that a combination of antidepressants and some form of psychotherapy is the most effective for the largest number of people. Then there are people who will not require a combination of treatments, responding well to one or the other.
Antidepressants change the chemical balance in the brain by targeting very specific areas. The various forms of psychotherapy also change brain activity but in a different manner. There are also a number of complementary or alternative treatments that are used by many people with varying degrees of effectiveness. While not all complementary treatments have been fully evaluated, initial trials are promising for a number of them, particularly St John’s Wort and omega 3 in fish oil tablets. Like prescription medication, individual responses to these treatments vary widely but they have certainly helped some people and are worth considering.
Psychotherapy alone is not a sufficient treatment for some people with depression. Individual need to be treated according to their specific needs. In many instances of depression a range of remedies is required. For many, the use of medication is essential and the only way to alleviate suffering. Some people have a strong resistance to taking medication because they feel it is a sign of weakness. People who have no problems taking medication for illnesses such as asthma or heart disease still feel there is a stigma attached to taking medication for emotional problems. Poor information may increase this stigma, jeopardise the path to recovery for some people and increase the risk of suicide. Some people require medication for a short time, others may have to remain on medication for life. It is vitally important to find a doctor who has the knowledge and will make the time to carefully and regularly monitor each patient on medication for depression. Often two or three antidepressants have to be tried before there is a positive response and there are instances where some medication has made a person’s depression worse. It is important to have a mutually respectful relationship with a doctor or therapist whom you trust. While GP’s are usually the first contact for a person with depression, not all are trained to deal with mental illness and a referral to a specialist should be asked for or offered. There are inadequate people in all professions and there are some doctors who are totally unqualified to treat any form of mental illness.
Many of the people I spoke with while writing my book had particularly strong views regarding treatments as a result of their own experiences. A number were very opposed to antidepressants being the first mode of treatment they were offered, arguing that while drugs did help to a degree they did not remove the underlying problem. As one person I interviewed said rather passionately: “Drugs for depression have been designed to help alleviate symptoms and not address the cause and that’s because in my view the doctors don’t seem to have a clue about the real cause of this bloody illness. I’m on drugs and I’m a bit better, but what happens when I stop taking the ‘frigging’ tablets?”
Again there were those who expressed eternal thanks that they were given antidepressants, enabling them to regain a life that was not hell on earth. Others were very critical of their therapists whom they believed had their own agenda’, were not flexible in their approach and did not tailor treatment to the individual. Others say their therapist saved their lives.
I stress that it is important to be assessed and treated as an individual, though if you are depressed it can be hard to negotiate and be involved in the management of your own health. If possible it is a good idea to have a family member or friend involved with the doctor or therapist in the management of your illness.
Young People and Depression
In a recent study released by community services organisation Mission Australia, young Australians ranked suicide and depression as the most important issue facing them and their peers.
A recent article in major Australian newspapers revealed that more school principals are reporting an alarming rise in the numbers of children having mental health issues including depression. About 2% of primary school children in Australia have been diagnosed with depression. This could be caused by body image problems, bullying, family breakdown and drug and alcohol abuse.
Bullying has direct links to depression and youth suicide. Being bullied as a child can leave emotional scars that can last a lifetime. The bully themselves could be depressed. The bully in fact could be feeling unloved, insecure and use aggressive and hurtful behaviour to gain a sense of control and empowerment.
We miss many opportunities for prevention and intervention with school children. It is hard to feel that you can influence the many social determinants that can affect teenagers. Parents and primary school teachers need to be trained to help identify childhood mental health problems. Preventative intervention in childhood can halt the onset of depression. It is ideal if the school environment can be prepared to teach such life skills. Cumulative adverse life events and poor social and coping skill can lead a young person into depression
The National Health and Medical Research Council have estimated that by the time young Australians have reached the age of eighteen, 24% will experience a major episode of clinical depression. Over the last fifty years the average age of first onset depression has moved from twenty-nine years to sixteen years. Factors such as relationship problems with family members and peers, early trauma or abuse and substance abuse are highly correlated with depression in young people.
Australia is losing a battle right in front of our eyes and the results are devastating – we are losing the fight against youth suicide. Australian youth suicide is one of the worst in the world. Only Canada, New Zealand, Armenia and Russia have worst statistics than ours. In Australia the suicide rate for young men has tripled over the past 40 years.
Substance Abuse and Depression
It is not uncommon for people to use drugs and alcohol to cope with their depression. There is a definite link between substance abuse and depression. Sadly many people use mind- altering substances to try and avoid or hide depressive symptoms. They will not help you feel better overall and may actually hasten the depressive response. Mood fluctuations and negative feelings can be exacerbated and for example, what might be irritability can accelerate into destructive anger. Alcohol misuse in depression is common, with rates being higher in men. Depression can be exacerbated by alcohol use and can also be secondary to alcohol abuse. Alcohol abuse can also reduce the effectiveness of depression treatment.
Conclusion
My two interests, the arts and mental health have overlapped as I have been interested to read about the connection between creative people and depression and other mental health illnesses. Earnest Hemingway and Virginia Woolf come to mind immediately when thinking of writers who suffered from depression. I personally know a number of artists and musicians who fight this crippling illness. Some claim to do their best work when emotionally imbalanced.
I suppose I have become a real advocate for improvement in the mental health system and for better understanding of mental illness. This happened overtime as I learnt more about depression and other mental illness during the time I researched the material for my book. Since friends and work associates knew I was writing about depression I am amazed at the number who have told me they had or have suffered from depression.
I am on the Board of depressioNet which is an internet help service for depression sufferers and their families. Depression had become a big part of my life and I feel really blessed that I have not suffered from it. Like all human beings I have my low moods and my moods can fluctuate without any perceptible cause, but I have always been able to continue to function even when feeling very ordinary emotionally.
I salute the bravery and the guts of many depression sufferers who continue to fight against the dreaded ‘black dog’.
Depression must be recognized as an illness that is beyond the control of the sufferer. Those suffering from clinical depression do not need or deserve to be told to ‘pull their socks up’ or ‘snap out of it’. It is a tragedy that many people suffer from depression for years before they are diagnosed.
To lose hope is to lose everything in the fight against this terrible illness. And yet hope is often the first emotion to go when depression strikes. The battle to maintain hope is often left to the family and friends of the sufferer. It is a gift to the sufferer if they can help keep hope alive and it will help the outcome if the sufferer believes it is achievable to gain control over the feelings of desperation, powerlessness and hopelessness that are the hallmarks of this illness.
It is important to remember that most people with depression can be helped. There are many people out there who have beaten or at least learnt to manage their illness.
By Maria Prendergast—March 2008
