Clinical Depression - Fact Sheet
It is hard for people who have not experienced clinical depression, either personally or by regular exposure to people suffering it, to understand its emotional impact and severity, interpreting it instead as being similar to "having the blues" or "feeling down."
As the list of symptoms below indicates, clinical depression is a serious, potentially lethal systemic disorder characterized by the psychiatric profession as interlocking physical, affective, and cognitive symptoms that have consequences for function and survival well beyond sad or painful feelings.
What this means is that depression is a whole-body illness that impacts upon you physically, emotionally and even cognitively – slowing your thought processes and reducing your ability to concentrate – and must be taken seriously.
According to the DSM-IV-TR criteria for diagnosing a major depressive disorder, one of the following two elements must be present for a period of at least two weeks:
- Depressed mood, or
- Anhedonia (The absence of pleasure or the ability to experience it.)
In addition, at least five of the following ten symptoms must occur over that two week period:
- Feelings of overwhelming sadness and/or fear, or the seeming inability to feel emotion (emptiness);
- A decrease in the amount of interest or pleasure in all, or almost all, daily activities;
- Changing appetite and marked weight gain or loss.
- Disturbed sleep patterns, such as insomnia, loss of REM sleep, or excessive sleep (hypersomnia);
- Psychomotor agitation – unintentional and purposeless movements – or retardation – a slowing down of thought and a reduction in physical movements – nearly every day;
- Fatigue, mental or physical, and loss of energy;
- Intense feelings of guilt, nervousness, helplessness, hopelessness, worthlessness, isolation/loneliness and/or anxiety;
- Trouble concentrating, keeping focus or making decisions or a generalized slowing and obtunding (blunting) of cognition, including memory;
- Recurrent thoughts of death (not just fear of dying), desire to just "lie down and die" or "stop breathing", recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide;
- Feeling and/or fear of being abandoned by those close to one.
Types of depression: Endogenous and Exogenous
Some depression is primarily the result of upsetting and disappointing circumstances. This depression tends to resolve as circumstances improve or as the individual adjusts to the circumstances. This type of depression is called exogenous (coming from without) depression.
However, other forms of depression can be much more related to inherited body chemistry and are much less the result of circumstances. This can confuse individuals because their circumstances do not seem to warrant the depression they experience. These are called endogenous (coming from within) depressions.
Treatment
The most effective treatment for depression varies broadly among individuals, and the levels, types, and methods of intervention around the globe all vary dramatically. Various types and combinations of treatments may have to be tried. There are two primary modes of treatment, typically used in conjunction: medication and psychotherapy. A third treatment, electroconvulsive therapy (ECT), may be used when chemical treatment fails.
Medications
Most antidepressants are believed to work by slowing the removal of certain chemicals from the brain. These chemicals are called neurotransmitters (such as serotonin and norepinephrine). Neurotransmitters are needed for normal brain function and are involved in the control of mood and in other responses and functions, such as eating, sleep, pain, and thinking.
Antidepressants help people with depression by making these natural chemicals more available to the brain. By restoring the brain's chemical balance, antidepressants help relieve the symptoms of depression.
The four main types of antidepressants are
- Tricyclics
- MAOIs (Monoamine oxidase inhibitors)
- SSRIs (Selective Serotonin Reuptake Inhibitors)
- SNRIs (Serotonin and Noradrenaline Reuptake Inhibitors)
Each group of drugs has their own side effects and modes of action.
In general when taking antidepressant medication it is advisable to;
- Keep in touch with your doctor in the first few weeks. With some of the older Tricyclic drugs it's best to start on a lower dose and work upwards over the next couple of weeks. If you don't go back to the doctor and have the dose increased, you could end up taking too little. You usually don't have to do this with the SSRI tablets. The dose you start with is usually the dose you carry on with. It doesn’t help to increase the dose above the recommended levels.
- Try not to be put off if you get some side effects. Many of them wear off in a few days. Don't stop the tablets unless the side effects really are unpleasant. If they are, get an urgent appointment to see your doctor. If you feel worse it is important to tell your doctor so that he can decide if the medicines are right for you. Your doctor will also want to know if you get increased feelings of restlessness or agitation.
- Take them every day - if you don't, they won't work.
- Wait for them to work. They don't work straight away. Most people find that they take 1-2 weeks to start working and maybe up to 6 weeks to give their full effect.
- Persevere - stopping too early is the commonest reason for people not getting better and for the depression to return.
- Try not to drink alcohol. Alcohol on its own can make your depression worse, but it can also make you slow and drowsy if you are taking antidepressants. This can lead to problems with driving - or with anything you need to concentrate on.
- Keep them out of the reach of children.
- Tempted to take an overdose? Tell your doctor as soon as possible and give your tablets to someone else to keep for you.
- Tell your doctor about any major changes in how you feel when the dose of antidepressant is changed.
St. John's Wort (Hypericum perforatum) has been widely claimed to be effective as an antidepressant. The mechanism of action is unknown; and the active ingredient, if any, has not been ascertained.
It is potentially very dangerous if mixed with some medications and there is no published evidence that St. John's Wort is effective against severe depression, which, in any case, should receive professional help. For mild depression, psychotherapy directed at resolving the cause of the depression might be more prudent.
Psychotherapy
There are several approaches to psychotherapy – including cognitive-behavioural, interpersonal, psychodynamic and dialectical behaviour therapy – that help depressed individuals recover. Psychotherapy offers people the opportunity to identify the factors that contribute to their depression and to deal effectively with the psychological, behavioural, interpersonal and situational causes. Skilled therapists such as licensed psychologists can work with depressed individuals to:
- Pinpoint the life problems that contribute to their depression, and help them understand which aspects of those problems they may be able to solve or improve. A trained therapist can help depressed patients identify options for the future and set realistic goals that enable these individuals to enhance their mental and emotional well-being. Therapists also help individuals identify how they have successfully dealt with similar feelings, if they have been depressed in the past.
- Identify negative or distorted thinking patterns that contribute to feelings of hopelessness and helplessness that accompany depression. For example, depressed individuals may tend to over generalise, that is, to think of circumstances in terms of 'always' or 'never.' They may also take events personally. A trained and competent therapist can help nurture a more positive outlook on life.
- Explore other learned thoughts and behaviours that create problems and contribute to depression. For example, therapists can help depressed individuals understand and improve patterns of interacting with other people that contribute to their depression.
- Help people regain a sense of control and pleasure in life. Psychotherapy helps people see choices as well as gradually incorporate enjoyable, fulfilling activities back into their lives.
ECT
ECT is a treatment of psychiatric disorders in which a brief electrical current is passed through the brain of the anaesthetised patient using a specialized machine. There is a convulsion which is modified by muscle relaxants.
ECT is a safe and very effective treatment of major depression and other disorders such as catatonia, and has been used continuously since the 1930s. Death during ECT is extremely rare – in fact, ECT is safer than dental extraction under anaesthesia and does not cause brain damage.
Memory difficulties may follow ECT, however these usually subside within a few weeks. Most people who claim subjective memory difficulties post ECT have no objective difficulties on testing.
Even in instances where ECT seems to have caused some memory loss it is important to remember that both depression and antidepressant medication are also associated with memory difficulties.
ECT has had some very bad publicity over the years, largely from the uninformed.
Like all invasive medical procedures it is frightening to many people and in response to these fears it is strictly regulated.
The fact is that ECT has been an accepted treatment for major depression for over 70 years and that during that time it has saved countless lives.
Treatment-resistant depression
Although treatment is generally effective, in some cases the condition does not respond. Treatment-resistant depression warrants a full assessment, which may lead to the addition of psychotherapy, higher medication dosages, changes of medication or combination therapy, a trial of ECT/electroshock, or even a change in the diagnosis, with subsequent treatment changes. Although this process helps many, some people's symptoms continue unabated.
In emergencies, psychiatric hospitalization is used simply to keep suicidal people safe until they cease to be dangers to themselves.
References and further information
- Beyond Blue – http://www.beyondblue.org.au
- Depression: Mayo Clinic - http://www.mayoclinic.com/health/depression/DN99999
- HealthyPlace.com: A community of people providing mental heath information, support and the opportunity to share experiences helpful to others - http://www.healthyplace.com/
- Royal College of Psychiatrists -
http://www.rcpsych.ac.uk/mentalhealthinformation/mentalhealthproblems/depression/antidepressants.aspx - Sane Australia - http://www.sane.org.au/
- You Can Cope: Changing the Way We Deal With Life’s Problems Will Enhance Our Ability to Cope. Author: Peter Stebbins. Available from the Brain Injury Association of Queensland
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