DEPRESSION David M. Ndetei Introduction It is normal to feel fed up or miserable or sad for a few hours, days but not much longer than one to two weeks. There may be a reason for this we can understand, but sometimes there is no apparent reason. We usually overcome this on our own or simply talk it over with a trusted person. However, in depression, these feelings carry on for weeks or months and are so bad that they interfere with life. Depression is very common. Five to six percent of the population will have a depressive disorder during the course of their lives. It affects people of all races and socioeconomic and cultural backgrounds and affects twice as many women as men. The reasons for these gender differences are not clear. It may be that men are less likely to talk about their feelings and more likely to deal with them by drinking heavily or becoming aggressive. Women are more likely to have the double stress of having to work and look after children. Depression is important not only because of lost productivity and the pain it causes to the individual and the family. It is also significant because of the cost to human life through suicidal attempts and actual suicide. Depression will therefore be discussed in some detail. How to recognize depression The cardinal symptom of depression is a persistent feeling of sadness (unhappiness) most of the time often accompanied by crying although one may feel a little better in the evenings. In addition to this, most people with depression will have at least five or six of the following symptoms. Loss of interest in life and pleasure in things or activities one used to enjoy Finding difficulty concentrating, remembering and making decisions Inability to cope with things that one used to before Feeling utterly tired, exhausted, without energy and slowed down Feeling restless and agitated Loss of appetite and weight (some people find they do the reverse, that is, over-eat and put on weight) Taking one to two hours to get off to sleep, and then waking up earlier than usual (some people find they do the opposite sleep too much). Loss of interest in sex Loss of self-confidence Feeling useless, inadequate, hopeless, and pessimism or guilt Avoiding other people Feeling irritable Feeling worse at a particular time each day, usually in the morning Thoughts of death or suicide, plans to commit suicide and suicide attempts Persistent physical symptoms that do not respond to treatment, such as headaches, digestive disorders, and chronic pain. (This particular symptom is very common in Africa).
People who are depressed also tend to suffer from anxiety and many turn to substance abuse. Substance abuse is discussed in detail in another chapter. A. Classification of Symptoms of Depression 1. Emotional (the mind) feelings of unhappiness that do not go away for over two weeks feeling that you want to burst into tears for no reason losing interest in things being unable to enjoy things feeling restless and agitated losing self-confidence feeling useless, inadequate, and hopeless feeling more irritable than usual thinking of suicide 2. Thinking (the mind) inability to think positively or hopefully finding it hard to make even simple decisions difficulty in concentrating 3. Physical (the body) losing appetite and weight (rarely, eating a lot and putting on weight) difficulty in getting to sleep (rarely, sleeping too much) waking earlier than usual feeling utterly tired constipation going off sex Note: Because of the frequently associated multiple aches and loss of appetite, many depressed people may think they are suffering from a physical illness. This stresses them further. 4. Behaviour Difficulty in starting or completing things---even everyday chores. Crying a lot---or feeling like you want to cry, but not being able to avoiding contact with other people. Making suicidal plans.
Making suicidal attempts---that may or may not succeed. If they succeed they kill themselves. Including in their suicidal plans and attempts those who are particularly close to them such as family members. 1. Psychotic Symptoms In very severe depression: The patient may without any justification feel guilty, that they are worse than anybody else and in the end they may believe that they do not exist. Hallucinations, that is, hearing voices, seeing visions or smelling and feeling something that is not really there. It is not always that a depressed person recognizes that he/she is depressed, especially if the depression sets in slowly and gradually over a long period of time. Instead of recognizing the depression, the person may blame himself for being lazy and just struggle along with little strength and motivation. It is not unusual for another person who knows the depressed person to point out the possibility of depression. Majority of the people with depression in developing countries do not get help and yet treatment can alleviate the symptoms in over 80% of cases. Because it often goes unrecognized, depression continues to cause unnecessary suffering. The types, frequency, severity, and longevity of symptoms vary greatly from one individual to another and in the same individual from time to time. Without treatment, symptoms can last for weeks, months, or years. Types of Depression Just like many physical conditions such as diabetes, heart disease, and high blood pressure, depressive disorders come in different forms, with overlaps of symptoms, severity, and persistence. 1. Major depression: is manifested by a combination of symptoms that are severe and disabling enough to interfere with the ability to work, sleep, eat, and enjoy once pleasurable activities. A major depression can occur once, twice, or several times in a lifetime. 2. Dysthymia: This is a less severe type of depression that involves long-term, chronic symptoms that do not disable, but keep you from functioning at "full steam" or from feeling good. A person with dysthymia can also experience major depressive episodes. 3. Bipolar disorder: This is discussed in detail in the chapter on Mood disorders. Depression in Special Age Brackets 1. Depression in children Depression occurs in at least two out of every 100 children before adolescence although it is less common in children than in adults. It is more likely to occur if the children come from broken homes, have suffered from abuse or neglect, or have lost a parent early in their life or have childhood illness. Depressed children often display an irritable rather than a depressed mood, and show varying symptoms depending on age and situation. Most exhibit a loss of interest in
school and a decline in academic performance. They may be described as clingy, demanding, dependent, or insecure. Diagnosis may be delayed or missed when symptoms are interpreted as normal moodiness. 2. Depression in adolescence Clinically diagnosable depression affects five in every 100 teenagers. It can cause interference with daily activities, including deterioration in academic performance, a loss of interest in friendships and a decreased enjoyment in activities and hobbies. Depression is a major cause of suicide among adolescents. 3. Depression in the elderly There are special reasons why the elderly get depressed. As people get older, they are more prone to physical diseases, such as diseases of the joints (arthritis) which limit their movements leading to isolation and loneliness. They have higher chances of losing life-long partners or close friends through death. They may be concerned with what old age portends for them socially, economically, and physically. Besides the other symptoms of depression, deeply depressed elderly people may develop what looks like memory loss which may be mistaken for dementia when in fact it is not. 4. Depression after childbirth There are two conditions: (i) "Baby blues"---feeling of sadness, anxiety and irritability, following childbirth affects about 85% of all mothers and is generally considered a normal reaction to childbirth. It is usually short-lived, starting a couple of days after the birth and typically easing off by the end of the second week. The best form of help is support from family and friends and the opportunity to take regular rests. (ii) Postpartum depression---affects about 20% of new mothers. The general "baby blues" feeling does not go away and develops into a full depression or the depression may set in a few weeks after birth. What Causes Depression? It is not clear why some people do not get depressed and why, for those who get depressed, they take different types or severity. For each person, there is a complex, individual pattern of factors that work together to either allow or prevent depression at any given time. While sometimes it is possible to identify some factors that trigger depression in some people, in others there is no apparent trigger even for individuals whose lives are going well. Some possible reasons include: 1. External events. Loneliness and relationship difficulties within and outside family, financial worries, legal problems, retirement, grief due to the death of a loved one, changed and worrying circumstances, etc. may trigger depression. 2. Genetics. People with close relatives who have had depression may be more vulnerable to depression when something upsetting happens. 3. Medical illnesses. Strokes, diseases associated with the pituitary gland in the brain such as Cushing s disease, and thyroid problems are often closely linked with depression. Other, for
example, cancer and chronic physical diseases, lead directly to depression since they act as stressors. Various medications, such as treatments for high blood pressure, birth control pills, and steroids (like cortisone), alcohol and other commonly abused substances may also cause depression. Younger people may become depressed after acute viral infections, like flu. However, whether or not there are identifiable triggering factors or not, the final pathway to depression is imbalance of some brain chemicals that are essential in the communication, or transmission of messages from one brain cell to another. Several of these chemicals have been identified and studied but there are still many more in existence about which very little is known. Treatment Why it is Important to Treat Depression Four out of five depressed people will get better without help but this can take four to six months or even longer of suffering, unproductivity and the risk of suicide. One out of five remains depressed two years later. A small number of people with depression will eventually commit suicide. More importantly, it is not easy to predict who will get better without treatment. If you have one episode of depression, you have a 50% chance of getting another. Up to 80--90% of all depressed people respond to treatment and nearly all depressed people who receive treatment see at least some relief from their symptoms. Before treatment is instituted, there is need for a complete evaluation to identify any triggering factors as discussed earlier. A complete history should be taken to understand the time frame of the depression and the family and social dynamics of a particular person. A physical examination to rule out possible physical causes should also be done. A detailed history then needs to be taken to elicit or rule out the various symptoms of depression described earlier. Methods Used in the Treatment of Depression These can be divided into three major categories: (a) antidepressants; (b) psychotherapy and, (c) Electroconvulsive Therapy (ECT). The first two can be used alone but there is a better outcome if they are used in combination---that is, antidepressants together with psychotherapy. ECT is used as a last resort. (A) Antidepressants These are medications that work by correcting the chemical imbalances in the brain that are believed to be the final pathway to depression. Antidepressants are useful since 70% of depressed people respond to them. There is a very wide range of antidepressants available on the market. How Long Should One Take Antidepressants? Generally all antidepressants are equally successful, provided that an effective dose is taken for a sufficient period of time. This is because antidepressants need to reach a certain level before they begin to work. The level of the dose varies for different antidepressants. For some antidepressants, there is need to start at a lower dose and build up to the effective dose. Second, antidepressants do not work quickly, and for most people, it takes two to three weeks to see an effect from an adequate dose. In some cases, it may take up to eight weeks for the medication to
take effect. This is why it is very important to persevere in order to give the treatment a full chance of working. Many people are impatient, expect instant results, and therefore stop taking medication before they have given it a chance to work. If an antidepressant works well for a person, it is advisable that they remain on it for some time, no matter how well they feel. It may be up to four to six months before one can start gradually reducing the dose. If there has been more than one episode of depression, it is advisable to remain on the antidepressant for much longer. Third, there is the possibility of getting withdrawal symptoms such as anxiety, diarrhoea and vivid dreams if the antidepressant is withdrawn suddenly. The chances of relapse into a depressive state are higher if the antidepressant is withdrawn suddenly or prematurely. Not everybody responds to given antidepressants. Once the maximum tolerable dose of an antidepressant given over a certain period of time does not work, another antidepressant should be tried. In some cases, a combination of antidepressants is indicated. Different Types of Antidepressants There are three different classes, or types of antidepressants: 1. Tricyclic Antidepressants (TCAs) 2. Selective Serotonin Reuptake Inhibitors (SSRIs) 3. Monoamine Oxidase Inhibitors (MAOIs) 1. Tricyclics---What exactly are they? They have been in use since late the 1950s/early 1960s. There are several types of tricyclics each having a slightly different mode of action. They are effective in treating depression and are also sometimes used for other reasons, like pain relief, for treatment of anxiety and to help people sleep. Millions of people have taken these antidepressants and have recovered from depression by using them. They are affordable and therefore even those who are poor need not suffer from depression for lack of antidepressants. One month s supply costs less than the equivalent of one US dollar. Most unfortunately, TCAs, which are very effective when used judiciously according to instructions, have been demonized contrary to evidence. Chief among those who are against the use of TCAs are drug companies which see no prospects of profits through the use of these drugs and are more concerned with selling new preparations and brands. It is now a scientific fact that most people of African descent require a lower dose than people of Caucasian descent. However, like with any other drug, one has to be cautious especially if one suffers from epilepsy, diabetes, glaucoma, heart complaints, liver problems, kidney problems, and prostate trouble. Like with any other drugs, the patient must inform the doctor if he/she is taking any other drug for other conditions, or if she is pregnant or planning for a pregnancy or breastfeeding. TCAs are dangerous if an overdose is taken. However, this is most unlikely to occur if the patient is advised exactly how to take the medicine. The chances are minimized further if the relatives are asked to take charge of administering the medicine exactly according to the dose prescribed. If however, overdosing happens, the person must be rushed to hospital as an emergency where an antidote of a glass of what is called "activated charcoal," is administered. Activated charcoal reduces the amount of the drug absorbed into the body but it only useful if it is given before absorption from the stomach begins.
2. Selective Serotonin Reuptake Inhibitors (SSRIs) and other related antidepressants The SSRIs are among the newer antidepressants and have been available since 1988. There are several types of SSRIs, each having a slightly different shade of action. SSRIs target one particular brain chemical substance known as serotonin and they act by ensuring that this chemical moves on to the next nerve cell in the brain instead of going back to the previous brain cells. Related to SSRIs are other antidepressants which have selective action on other brain chemical substances other than serotonin or in combination with serotonin. SSRIs are effective in treating depression and are sometimes used for other reasons like treatment of anxiety or panic and some eating disorders. They are widely used and millions of people who have taken them have recovered from depression. There are some conditions where extra care should be taken such as, if one is taking other medication, is pregnant, breast feeding or trying for a baby. 3. Monoamine Oxidase Inhibitors (MAOIs) These are antidepressants that work by preventing the breakdown of the chemical substances that are necessary for effective communication between nerves. The MAOIs have been around for about 30 years and are effective for all types of depression, including depression where people eat and sleep more than usual, and depression where other antidepressants have not worked well. Millions of people with depression have taken them and have recovered using them. They are not widely used because they have a reaction with certain foods. There is however one type of this class of antidepressant--- moclobemide---which does not react adversely with food like other MAOIs. MAOIs should not normally be used, for example if one is suffering from the following (which should be told to the doctor): diabetes, epilepsy, hyperactive thyroid (hyperthyroidism), heart, and liver trouble. They should also not be used if one is taking certain types of medication such as are used for coughs and colds, during pregnancy and breastfeeding or when trying for a baby. If there is switching between an MAOI and another antidepressant, an interval of a week or two between treatments will be needed. Antidepressants in Young People There is need for caution in the use of antidepressants in teenagers, since some SSRIs have been shown to increase suicidal thoughts in young people. In the early stages, weekly supervision by a psychiatrist is necessary. Some Take-Home Tips for Those Who are Taking Antidepressants 1. Though lack of sleep improves much faster, the mood changes may take longer. 2. Take medication regularly at the times prescribed. Some are best taken in the morning, others at bed time while for others, the timing does not matter. 3. If you miss a dose, take it as soon as you remember, as long as it is only a few hours after the usual time. Otherwise, wait until your next dose is due and take it as usual---never try to catch up by doubling your next dose. 4. Taking alcohol with antidepressants is best avoided for several reasons: It can cause severe drowsiness and also delay or reduce the response to antidepressants.
5. Even if you feel much better or even free of symptoms of depression, it takes at least four to six months in most people, sometimes longer for the brain chemical to recover fully. Do not be in a rush to stop the medication; first discuss it with your doctor. For individuals with bipolar disorder or chronic major depression, medication may have to become part of everyday life to avoid disabling symptoms. 6. Once the doctor recommends that it is time to stop taking the antidepressants, the doses should be gradually phased out in a reducing manner rather than being stopped abruptly. The pattern of reduction should be discussed with the doctor. 7. Antidepressants are not addictive, neither are they habit forming, unlike the so-called benzodiazepines (the doctor and the pharmacist will easily point out to you which drugs belong to the class known as benzodiazepines). Antidepressants are quite safe when used for long periods of time. Although benzodiazepines and other anxiety-relieving and sleeping drugs are usually prescribed with antidepressants, they must not be taken alone at least in the initial stages when a person is depressed. They do not treat depression. 8. Antidepressants may cause mild and, usually, temporary side effects in some people. These vary widely from one individual to another. Though not serious, the symptoms which may be a nuisance, annoying and usually short-lived should always be discussed with a doctor. The most common side effects and ways to deal with them, are: Dry mouth---(more common with tricyclics); drinks lots of water; chew sugarless gum; clean teeth daily. Constipation---(more common with tricyclics); eat lots of fruit, vegetables, and other fiber-rich foods Bladder problems---emptying your bladder may be troublesome, and your urine stream may not be as strong as usual. Sexual problems---sexual functioning may change; if worrisome, discuss with your doctor. Blurred vision---this will pass soon; do not get new glasses. Dizziness---arise from a bed or chair or the toilet seat or from any squatting position slowly. Drowsiness---this will pass soon; do not drive or operate heavy equipment if feeling drowsy or sedated. Headache---this will usually go away. Nausea---even when it occurs, it is transient after each dose, and is more common with SSRIs. Nervousness and insomnia---(common with SSRIs) these may occur during the first few weeks; dosage reductions or time will usually resolve them. Agitation---this may happen early in treatment, and is usually transient, if not, consult your doctor. 9. Be sure to tell your dentist or any other medical specialist who prescribes a drug or the pharmacist that you are taking antidepressants. Some of the most benign drugs when taken alone can cause severe and dangerous side effects if taken with others. 10. Consult your doctor immediately should you fall pregnant or are planning a pregnancy when taking antidepressant (like with any other drugs). (B) Psychotherapy Treatment
The simplest definition of psychotherapy is talking treatment. It helps the patient to understand himself or herself, to understand the illness and in the process change his or her maladaptive thoughts, feelings, and behaviour. There are several forms of this "talking treatment" that have proven useful in helping the depressed person. 1. Counseling---Counseling enables you to talk about your feelings and concerns with an objective nonjudgmental professional person. This can be administered by a clinical or counseling psychologist, a member of the clergy or a pastor, a psychiatric nurse or a trained community-based mental health worker. Counseling can relieve the burden of your feelings. 2. Cognitive behavioural therapy (CBT)---CBT for depression is based on the premise that depression results when patients constantly berate themselves, expect to fail, make inaccurate assessments of what others think of them, feel hopeless, and have a negative attitude toward the world and the future. In CBT, the aim is to enable the patient reverse these negative perceptions of self and the world around them, and his/her future. It does this by helping the patient identify any unrealistic and unhelpful ways of thinking and then develop new, more helpful ways of thinking and behaving. It can be offered by the same kind of professionals who offer counseling. 3. Interpersonal psychotherapy---this is based on the premise that disturbed social, personal and interpersonal relationships can cause or precipitate depression, which in turn worsens these relationships. This therapy seeks to enable the patient to understand the disturbed relationships, how they contribute to the depression and how to improve the relationships. These relationships may be with family members, workmates or friends. 4. Psychodynamic psychotherapy---this therapy is based on the premise that current human behaviour, emotions and motivation are determined by the impact of one s past experience and genetic and cultural endowment on his current real life situation. It therefore involves talking about early childhood development, early family and life experience and how they affect or relate to the current situation.. 5. Self-help support groups---are useful especially for those people who have become depressed for the same or similar reasons such as torture, poor living conditions, disaster, disability or caring for a relative, etc. There is a lot of shared experience and support from members of the group. 6. Guided self-help---can include available information on print (like this book) or electronic formats 7. Problem-solving therapy---helps you to be clear about your key problems, how to break them down into manageable bits and how to develop problem-solving skills. 8. Couple therapy---if your depression seems connected with your relationship with a partner. 9. Bereavement counseling---if you are not able to get over the death of someone close to you, you need to talk about it with a specialist bereavement counsellor. 10. Group therapy---talking in groups can be helpful in changing how you behave with other people. You get the chance, in a safe and supportive environment, to hear how people see you and the opportunity to try out different ways of behaving and talking. Whereas selfhelp support groups are run by the patients themselves, group therapy is usually done with the help of a trained professional.
Some Few Take-Home Tips on Talking Treatments 1. They take time. A session lasts about one hour and you may need very many sessions. Therefore it can be expensive in terms of time and money if one has to pay for the services. 2. Talking about things can bring up bad memories from the past and this can make you feel worse for a while. 3. It can change people s outlook and the way they relate to friends and family, and can strain a close relationship. 4. Make sure that you can trust your therapist and that they have the necessary training. Self-Help for a Depressed Person 1. Should you feel you are depressed, talk to someone you trust and can confide in. Tell them how you feel and cry if the environment allows. This is good for healing. 2. Educate yourself by reading all you can about depression. The simpler the better. This book aims to fulfill that need. 3. Learn how to relax and reduce the tension, anxiety and irritability often associated with depression. You can use simple inexpensive remedies such as walking, physical activity, having a massage, etc which can be very effective in allaying anxiety and tension. 4. A change in lifestyle such as reduced workload so that you are in charge rather than work being in charge over you. 5. Diet---A well balanced diet which does not lead to overweight or even loss of weight. Fresh fruits and vegetables are particular helpful 6. Avoid drugs, such as cigarette smoking, illicit drugs such as cannabis and dependence on alcohol. Alcohol in particular is a depressant and despite giving a temporary lift can definitely worsen depression. Besides being bad for your health it can stop you dealing with important problems or from getting help. 7. Keep yourself occupied both physically and mentally, especially in activities that allow your mind to concentrate on something. 8. Take short breaks from the routine whenever possible 9. If you cannot sleep, try not to worry about it. Preoccupy yourself with something, try relaxation and you may feel less anxious and find it easier to sleep. 10. If you know what is causing your depression, write it down and think of possible realistic solutions. 11. Remember you are not alone and that there are millions of others suffering from depression and also millions who recover from depression. It may be that you will come out of depression stronger and better prepared to deal with or prevent the situations that caused the depression. 12. When feeling depressed, postpone important life-changing decisions since they may be coloured or influenced by negative perceptions. At What Point Do You Seek Help? The following are the earliest points at which you should seek help. 1. When your feelings of depression are more than usual and do not seem to get any better; 2. When your feelings of depression affect your work, interests and feelings toward your family and friends;
3. If you find yourself feeling that life is not worth living, or that other people would be better off without you (For more details see chapter on suicide). What Do You Do When a Family Member Or Friend is Depressed? 1. Provide a caring, supportive environment for the depressed person. 2. Be patient with him/her---even on good treatment, recovery can take some time 3. Do not pressure him/her with expressions such as get your life together 4. Encourage him/her to consider review of treatment or even seeking a second opinion if weeks go by and the symptoms remain unchanged or worsen. More often than not, personal rapport with a mental health worker is necessary for optimal response to a given treatment. 5. Hopelessness may lead the depressed person to think of, consider, plan or even attempt suicide. Ensure they are not left with or have access to larger amounts of drugs than are needed. Keep all household poisons and insecticides away. Ensure that the person is never left alone. Always be on the lookout for such, and if you suspect such behaviour, do not hesitate to confront the patient about it (for more details see chapter on suicide). 6. Help the patient to take the medication exactly as prescribed. If you have reason to suspect he may be suicidal, take charge of keeping and administering the medicine. 7. Engage the patient in a friendly and positive dialogue about anything that may be contributing to, precipitating or sustaining the depression. Even if you may not be able to do anything about those factors, the fact that you show concern and give a listening ear may be all that the patient requires or treasures most. By so doing, you demonstrate sensitivity in regarding the patient as a normal human being going through difficulties. This may require patience in listening even to repetitions of the same thing over and over again. This requires you to spend time with him/her. 8. It is usually best not to offer advice unless it's asked for, even if the answer seems perfectly clear to you. If depression has been brought on by a particular problem, you may be able to help find a solution or at least a way of tackling the difficulty. 9. It is helpful just to spend time with someone who is depressed. You can encourage them, help them to talk, and help them to keep going with some of the things they normally do. 10. Someone who is depressed will find it hard to believe that they can ever get better. You can reassure them that they will get better, but you may have to repeat this over and over again. 11. Make sure that they are eating enough. 12. Help them to stay away from alcohol, any other non-prescribed or illicit drugs.. 13. If they are getting worse and start to talk of not wanting to live or even hinting at harming themselves, take them seriously. 14. Encourage them to accept help from a mental health professional 15. Depression is not a sign of personal weakness. It can happen to the most determined persons. Depression is not a respecter of persons. (C) Electroconvulsive Therapy (ECT) This is indicated in a case of major depression that is not responding to antidepressants; there are psychotic features and/or strong suicidal and failure to eat. Despite negative publicity, ECT, where properly indicated, is the most effective treatment for severe depression, bringing results in about two weeks. It is also the safest form of treatment, especially with modern machines that
are able to calculate the amount of electric current to use and for how long (usually 3.5 4.5 seconds). Administration of ECT involves the use of an electronic current passing through the contacts (electrodes) placed on the back the temporal part of the skull. It is done in theatre. A short-acting general anesthesia is administered to induce sleep and muscle relaxation. A psychiatrist administers the ECT. For details consult a doctor.