«Dr Patrick McKeon Julie Healy Geraldine Bailey and Gerry Ward Depression Keeping hope alive A guide for families & friends Series Editor: Dr. Patrick ...»
keeping hope alive
A guide for families & friends
Dr Patrick McKeon
and Gerry Ward
Keeping hope alive
A guide for families & friends
Series Editor: Dr. Patrick McKeon
DEPR ESSIO N
Depression is like a big hole,
You are all by yourself without a soul
You are all upset
You are all scared
You feel as if no-one cared
You feel upset
You feel bad
You feel worried
You feel sad
You feel like everything is in a flurry It is like one big worry Bridget Cantwell Aged 11 Contents Preface 2 Introduction 3 Part I What is a Depressive Illness? 4 Depression: Signs and Symptoms 5 How Common is it? 6 Are There Different Types of Depression? 7 Bipolar Disorder 8 Elation or Mania: Signs and Symptoms 9 What Causes Depression? 9 Depression in Children 11 Treatment 14 Part II Your Role as a Relative or Friend 18 Why the Divide 20 How Families React to Mood Disorder 22 Effect of Mood Disorders on Children 23 Advice for Relatives and Friends 24 Glossary of Terms 32 Suggestions for Further Reading 37 ©2000 Dr Patrick McKeon, Julie Healy, Geraldine Bailey, Gerry Ward and Aware Preface If somebody close to you has become depressed, you will know by now that this is not a trivial condition. As illnesses go, it is under rated by those who have not experienced it, under reported by those who are in its grip, and because of these factors and others it is significantly under treated. Yet, one in three people have a full-blown depressive episode at some stage in their lives. In reality few, if any, people go through the different stages of life without some experience of depression.
The pages which follow, will give you an understanding of depression, what it is, why it occurs, and how it can be treated. More importantly, it sets out how you can gain an understanding of depression, so that you can both help the person about whom you are concerned and experience less worry and uncertainty. We would hope that on reading this you would have an understanding of how you can keep hope alive until the mood disorder has been successfully treated.
Introduction You may be surprised to be reading this booklet and may never have thought that somebody close to you would get so depressed, but then they probably never thought so either. It catches a lot of people by surprise. Currently there are 300,000 Irish people, or 1 in every 14, who have depression. In the course of the average lifetime, there is a one in three chance of having a full-blown depressive episode and a further third will have lesser degrees of depression. So, depression is common.
Depression affects a person’s thinking, feeling, and behaviour. It is an illness in the sense that it is disabling and beyond the person’s coping ability. For most who experience it, they describe it as one of the worst things that ever happened to them. For some, as they grapple to find words to convey the horror they have been through, it seems more devastating than losing a close family member or of facing death with cancer.
For you as a relative or friend of somebody with depression, it is also devastating. At times, you will feel bewildered, upset, frustrated, agitated, or downright dejected. I hope that you will find within the pages which follow, that depression can be mastered. Knowing how to recognise it, the subtlety of its signs and symptoms, how it should be treated and what you might expect in terms of its future course will enable this mastery. But knowledge alone is not sufficient. Having gained this knowledge you must address your own feelings about depression and how it has affected your life. This you can best do by working in partnership with the person who is depressed and the treating doctor or therapist. Depression, as a disorder of emotions, affects those to whom the person is bonded emotionally. If that person is you, you have an important part to play in aiding that person’s recovery.
PART I What is a depressive illness?
A depressive illness is a disabling, overpowering experience affecting thinking and the way a person feels, disturbing sleep, appetite, and energy. At some level, the person feels unable to cope. It is useful to distinguish it from normal depression, that is, the ups and downs of every day life. These normal shifts of mood are relatively mild and tolerable and we can cope with them. When depression is more prolonged and/or intense, such that it is beyond the person’s ability to function normally, it is referred to as a depressive illness. Clinical depression is an alternative term, simply meaning that it is sufficiently disruptive to warrant getting clinical or medical help.
You don’t have to feel depressed to be depressed Depression frequently goes unrecognised for a variety of reasons. For one, in its early stages, it is so like a normal depression that it merges imperceptibly with it, so that it can be hard for the person to see the gradual deterioration in mood. Another explanation is that the person often does not feel depressed, but is mainly aware of tiredness, disturbed sleep, poor concentration or memory or reduced appetite. Indeed, tiredness, wakening during the night, being anxious and apathetic are the more common early symptoms. It is often only when the depression is more advanced that the person will actually feel depressed. So, it useful to think of most depressions going through different stages of severity. In the mild stage, anxiety, self-doubt, poor concentration and tiredness are the main symptoms. In a moderate depression, feelings of bleakness, depression, guilt, loss of interest and general slowing of thinking are more evident. In both mild and moderate forms, the symptoms listed are often more evident in the morning and lessen or have disappeared in the evening. A severe depression is characterised by a worsening of the features of a moderate depression resulting in slowness of walking, being quiet or withdrawn even to the point of being mute, being unable to eat, wash or dress. In addition, delusional beliefs or false ideas, such as believing one is bankrupt, terminally ill or has done some serious wrong, can be a feature of severe depression.
Hallucinations, that is hearing voices or having visions, can also occasionally occur and they usually concern the same negative and guiltridden topics as in depressive delusions.
It is vital to realise that although you may observe these different stages of severity, the person who is experiencing them can often feel just as distressed in a mild depression, when they do not necessarily look depressed, as in a moderate depression, when you and others can see quite clearly that the person is unwell. It is particularly important to be aware of this as the person is recovering, when they move from a severe or moderate depression to a milder form. In the latter, they may look well but still feel miserable. You may think they have recovered as they appear brighter, but it is often at this stage that the person has a higher risk of suicide.
Depression: Signs and Symptoms
• Fatigue that is not relieved by rest
• Anxiety about trivial matters that previously were not of concern
• Feeling sad, depressed, empty or bored
• Poor concentration and memory
• Loss of interest in sex, hobbies, personal appearance, work, religion or whatever previously was of particular interest to the person
• Social withdrawal due to self-consciousness, loss of interest and quietness
• Slowing of thinking, speech and activity or restlessness in those who have an anxious pre-illness personality
• Sleep disturbance - difficulty in getting to sleep, wakening repeatedly during the night or very early in the morning. Despite these complaints they may have been observed to have slept well
• Oversleeping which can often be combined with a broken sleep pattern or early morning wakening
• Increased or diminished appetite
• Feelings of guilt, worthlessness or inadequacy
• Headaches, chest, abdominal or back pains with no physical basis
• Suicidal thoughts, recurring thoughts or dreams of death
• Delusions and/or hallucinations If a person has feelings of anxiety or depression and 4 or more of the above symptoms for longer than two weeks, they meet the diagnostic criteria for Major Depression (set out by the Diagnostic and Statistical Manual - DSM IV) and they should seek medical help.
How common is it?
About 7% of the population have a clinical depression at any point in time.
Women are 3 to 4 times more likely than men to have depression. Surveys show that depression occurs more frequently during the teenage years and in old age. These stages of life and after childbirth are times of major change in levels of sex hormones and in relationships, expectations, and outlooks.
While 70% of women will have a mild short-lived or a ‘normal’ shift in mood following the birth of a baby, 5-10% of women will have a disabling post-natal depression.
There is evidence to suggest that the mild to moderate forms of depression are on the increase, but the more severe biological depression, such as manic depression, also known as bipolar disorder, have not altered in frequency over the years. In addition, for the more severe depressions it is likely that there is no difference in the rate of occurrence between the sexes.
Depression is one of the most under diagnosed and under treated illnesses.
Of every 4 people with depression in the community, only 2 will seek help and of those, only one will get adequate treatment. This means that only 25% of people with a disabling and potentially fatal condition get the appropriate help.
Are there different types of depression?
There are many different forms of depression, but as we do not fully understand how the different factors causing depression interact or exactly what happens in the brain, there are several different ways of classifying it.
These methods have changed over the years.
Currently the most favoured way of classifying depression is to do so according to the pattern of occurrence of the signs and symptoms.
In the diagram above, mood disorder is divided into unipolar and bipolar disorder. Mood swings can be represented as swinging down at one end of the mood spectrum, the low pole, and up to the other end of the spectrum in Bipolar disorder. Hence “uni” refers to “one” pole or form of depression. We already referred to major depression, where the features of depression are present for longer than 2 weeks. This can further be divided into a single episode or a recurring pattern of depression. Dysthymia refers to an ongoing low-grade depression, often lasting longer than 2 years.
Bipolar disorder can be further subdivided into bipolar I disorder, where there are two poles, a depression and elation or mania, where the mania is of a severe, disabling nature. Under DSM - IV criteria, the features of mania need to be present for at least one week to be categorised as bipolar I disorder. In bipolar II disorder there are episodes of depression alternating with bouts of mania of a lesser degree, referred to as hypomania, where the signs and symptoms are present for four or more days. Both unipolar and bipolar mood disorder tend to recur as 70% or more patients can expect further episode. When the recurrence of mood disorder is particularly frequent, with 4 or more episodes per year, it is referred to as a rapid cycling mood disorder.
Another way of classifying depression is on the basis of the principal cause of the depressive episode. Reactive depression is purely an understandable reaction to a significant loss and the symptoms are of anxiousness, sadness, tension, irritability, feeling worse in the evenings, and having trouble getting to sleep at night. Reactive depression is the usual initial response to loss and it is the same as grief. It is important to realise the symptoms and signs of endogenous depression, which I will describe next, are not present.
Endogeneous depression is due to internal biological factors and frequently occurs after little or no stress. It has its symptom profile, fatigue, emotional deadness, broken sleep pattern or early morning wakening, tending to feel worse in the morning, and a progressive loss of interest in food, sex, or in whatever was of particular interest to the individual. Where stress or a loss has precipitated the first episode of endogeneous depression, it tends to be less important as a trigger for subsequent recurrences.
A personality based or neurotic depression refers to depression that occurs as a result of the way the individual is coping with life’s problems. If an individual has difficulty asserting themselves, is extremely perfectionistic or rigid in their approach to life or is unduly anxious, it becomes difficult for them to cope with day-to-day stress. Consequently, recurring depressions of a reactive nature develop.
Secondary depression refers to depressive episodes that occur as a consequence of some other psychiatric illness such as schizophrenia, phobic states, or alcohol or drug dependence, or as a result of a medical disorder, such as Parkinson’s disease or after a viral infection or a stroke.
Bipolar Disorder Bipolar disorder or manic-depressive illness tends to be a more severe form of mood disorder that affects men and women equally and occurs in about 1% of the population. It consists of periods of elation or mania, alternating with bouts of depression. The depressive episodes last weeks to months and symptoms are indistinguishable from those of unipolar or endogenous depression. The signs and symptoms of elation are the direct opposite to those of depression. The person’s thoughts are racing; they are usually overtalkative, restless, overactive and need little sleep. While the word elation and mania (meaning speeded up), are used interchangeably, elation is not always a pleasant or euphoric state. It can be unpleasant for the individual in that they feel irritable, tense, tired, restless, or angry. This stage is usually referred to as a dysphoric (meaning unpleasant) manic state or a mixed mood. Hypomania refers to a lesser degree of mania. For 50%
- 70% of those who have an episode of bipolar disorder, the illness will recur.
Elation or Mania: Signs an Symptoms