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«Dr Patrick McKeon Julie Healy Geraldine Bailey and Gerry Ward Depression Keeping hope alive A guide for families & friends Series Editor: Dr. Patrick ...»

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• Feeling “high” or “on top of the world”, “better than normal”, or “better than ever before”

• Uncharacteristic irritability or anger

• Great energy and not needing to rest

• Overactive, restless or distractible

• Racing mind that cannot be switched off - “pressure in the head”

• Talking rapidly and jumping from one topic to the other

• Decreased need for sleep

• Excessive and unrealistic belief in one’s abilities

• Poor judgement

• Increased interest in pleasurable pursuits; new ventures, sex, alcohol, street drugs, religion, music or art

• Demanding, pushy, insistent, domineering or provocative behaviour without the person necessarily realising that their behaviour has changed What causes depression?

While it is convenient to consider the effect of losses and upsets in life, personality, vulnerability, and inherited predisposition to mood disorder as distinct causes, it is often the cumulative effect and the interaction of these different factors that determines whether a person gets clinically depressed.

Studies of depressed people clearly show that losses in life, such as bereavement, physical illness, break up of a relationship, unemployment and financial difficulties, precede depression. It is often where there are several significant set backs in the months before the depression, when the person seems to have fought back by becoming more determined initially, that the mind eventually succumbs, as it goes through a form of grief or reactive depression. Childhood losses such as the death of a parent, marital breakdown or separation from parents through hospitalisation, predisposes to recurrent depression in adult life. It is also likely that smaller, but personally significant, losses in early life predispose to depression later on.

One of the most important antidotes to the losses of everyday life is having somebody in whom to confide. A supportive confidante does seem to limit the traumatising effect of ongoing problems such as financial difficulties, illness, or having a poor relationship with a key relative.

Hereditary factors have been shown, through family, twin and adoption studies, to be of major importance, particularly for the more severe, recurring depressions and bipolar disorder. Surveys of twins have shown that genetic factors contribute some 40% to the causation of depressions of a mild to moderate severity. For recurring unipolar depressions, 50% - 60% of the causative factors are genetic, while for bipolar disorder this figure rises to 70% - 80%. It is important to realise that these are statistical averages based on thousands of case histories and should not be used to determine the genetic vulnerability for an individual.

How a person copes with stress and loss is determined by their personality, which in turn is shaped by a mixture of genetic and early childhood experiences. What may be a mildly upsetting disagreement for one person may be a major catastrophe for somebody who is insecure and has difficulty asserting themselves. It has long been recognised that depression is more common in the winter months and mania and hypomania is more likely to occur during the summer. Unipolar depression occurs more frequently for the first time and recurs in late October or early November and in February or March. Seasonal affective disorder refers to a depression frequently occurring annually in December to February, when the person is tired, oversleeping, overeats, and may have a period of hypomania during the summer months. It would appear that the mood regulating centres in the brain can have difficulty with the changing meteorological conditions, such as the duration and intensity of daylight, that occur with the change of the seasons. For most, this results in a slight, but barely perceptible shift in mood, but for others it can be an overt, disruptive depression.

The mood regulating areas of the brain which are contained in the limbic system, can be affected by general medical disorders such as under active thyroid gland, viral illnesses, such as influenza or viral hepatitis, Parkinson’s disease, or multiple sclerosis, stroke or following the use of mood altering medications, such as steroids and blood pressure lowering medications.

Steroids and L-dopa, a treatment used in Parkinson’s disease, can induce mania, particularly in those who are predisposed to this condition.

It would appear that where there are significant losses in life or minor losses but with obvious personality vulnerabilities, depression is likely to be of a reactive type. For some it moves beyond this to an endogenous form of depression, where there is broken sleep, early morning wakening, morning worsening of symptoms, and marked slowing of body movements and the thinking process.

When there is a strong family history of depression or bipolar disorder, the person may become depressed without having any very significant upset.

Likewise, where this biological vulnerability is quite minor, it will often only result in a mood change when there are major upsetting life events.

Generally, it should be possible to understand any individual person’s depression in the context of their losses and stresses, life supports and underlying genetic and personality endowment.

Depression in Children Children, even infants, can be depressed. Surveys show that some 10% of adolescents aged 13-19 have major depressive disorder, while before puberty the rate of depression is less that 2%. It is now generally accepted that children under the age of 12 can develop bipolar disorder.





When depression occurs before the age of 12 it is most often related to difficulties the child is experiencing, such as bullying in school or parental conflict. At that age, depression is more common in boys. After puberty, genetic factors appear to have a greater role in causing mood disorder in that the most likely predictor of having depression at that age is having at least one parent who has had depression. It is not that upsetting circumstances, such as relationship difficulties, family strife, or peer pressure, are not important, but these events appear to have a more profound and prolonged effect on adolescents who have a family history of depression.

This familial inclination has been shown by other researchers to have a largely genetic basis.

Recognising the Symptoms The signs of depression in children are no different to those of adults (see page 4) but they may not be that obvious, simply because we do not expect a child to be depressed. If a baby gets separated from its mother when she is hospitalised, he may stop eating and lose weight. If the possibility of depression is not considered, the infant may have extensive medical investigations to determine the cause of the weight loss. The second difficulty in recognising depression in young people is that while all of the typical features of depression are present, they are not necessarily expressed in the same way as they are in adults. For example, lack of interest in work or in one’s appearance are the typical symptoms for a depressed adult, whearas a child will more often complain of boredom, in other words, a lack of interest in everything. When you enquire about this complaint of boredom, you will usually find that particular aspects of life, such as the football team or pop star they have an interest in, has now become “boring”.

Parents may find it difficult to recognise depression in their children because they are reluctant to see it and trivialise it by referring to it as “teenager’s moods”. While most of the mood changes that teenagers go through are mild and transient and are due to their fight to gain mastery over their life circumstances, it is important to recognise the symptoms of depression if they are present and not dismiss them lightly. This can best be done by going through the checklist of symptoms listed below and if you think that there are some definite symptoms present, you should discuss the matter with your family doctor. There is often a tendency to dismiss depression when it is apparently due to some recent let down, such as not being picked for the football team. A depression such as this may be just as severe, and the upset in life may have only been the precipitating factor, rather than the main cause of the mood change. For example, a family history of depression may predispose the young person to depression and the upsetting event was simply the final straw that triggered the depression. If depressive symptoms are present, it is important to decide how severe they are and to seek help if they are bothersome.

Depression: Signs and Symptoms

Fatigue:

Uncharacteristically moping about the house, looking tired.

Anxiety:

Worrying excessively about studies, what others think of them, their appearance, or global issues, such as poverty.

Feeling Sad, Depressed or Bored:

A depressed young person may look sad or unhappy, feeling defeated by events at school or in their social life, which they usually took in their stride. They will often complain of a poor relationship with peers or siblings, in that they feel unwanted or inadequate for no justifiable reason. They may complain of boredom, which is a general lack of interest, or have a specific loss of interest in a favourite football team or a particular school subject. Aggressive negative attitude, poor concentration or memory, forgetfulness or losing things, falling school grades. Appearing not to be listening.

Lack of Interest:

Often presents as boredom or lack of interest in their own favourite T.V.

programme or pop star, or in their own appearance.

Change of Appetite:

Not feeling hungry, but eating to please or over-eating

Social Withdrawal:

Due to anxiousness, lack of interest, self-consciousness, or feeling depressed. Thinking more slowly, rate of movement and expressiveness is reduced.

Sleep:

Over or under-sleeping, nodding off when watching T.V., in the classroom, or when listening to music, late for school.

Low Self-Esteem:

Feelings of guilt, worthlessness, or inadequacy. Blaming themselves for everything that goes wrong.

Physical symptoms:

Headaches, abdominal or chest pains, frequent visits to the doctor.

Suicidal:

Morbid thoughts or dreams of death or suicide.

Delusions:

Ideas that will not go away, of being inadequate, or “stupid” or “gay”.

Treatment Depression is an extremely treatable illness with some 80% of people responding to counselling or anti-depressant medication within a matter of weeks. The most common reasons for treatment failure are poor compliance with treatment and incorrect diagnosis.

The different types of mood disorder, namely reactive depression, major depression, recurring unipolar depression, bipolar depression and rapid cycling mood disorder, need individually tailored treatment plans. The plan needs to take account of the losses the person has experienced, their personality and genetic predisposition to depression, the level of family support and complications, such as alcohol abuse, or financial problems they are experiencing. It can be difficult to correctly diagnose the specific type and pattern of mood disorder. It is not unusual for people with recurring episodes of depression to overlook the short lived periods of over talkativeness, trouble getting to sleep at night, irritability or frenetic activity that characterise hypomania. While severe bipolar disorder occurs in 1% of the population in the course of a lifetime, lesser degrees of bipolarity are present in a further 2%. Obtaining accurate information from both the person with the mood disorder and a key family member is essential to ensure that the pattern of the illness is clearly identified and the appropriate treatment is given. It can take quite a lengthy time before the doctor is clear about how events in a person’s life, their personality and any inherited tendency to mood disorder are interacting to cause depression. Alcohol or drug abuse may not be mentioned in consultations with the doctor. When you are part of the management team, these causative factors and mood swing patterns are unlikely to be overlooked, and so the correct treatment approach can be started earlier. It is hard for the person to accept they are depressed, that they need help, and particularly so, if that help is medication.

It is even more daunting if the prospect of a recurring mood disorder has to be faced, with the almost inevitable need for ongoing mood stabilising medication. The person needs time and understanding as they adapt to these situations. Getting factual information about their mood disorder is essential. Equally vital is the importance of meeting with others who have come to terms with their illness and the need for treatment. Support group meetings, such as those organised by Aware throughout Ireland, provide an ideal forum to meet others with the same problem. Experiencing the support and understanding of fellow sufferers is invaluable; it frees the person to face the future and helps them realise that there is a life after mood disorder.

Explanation: The symptoms of depression are often bewildering for both the patient and family, and vital that a simple explanation is given of what depression is, why they are feeling so out of sorts, what causes the mood disturbance and how it can be best treated.

Counselling: At its simplest level this is an extension of listening to the person’s concerns and that of the family and to familiarise them with the facts on depression. The most important aspect of management of depression is undoubtedly making an emotional link with the person who is depressed. It is essential that this link be established, as the pessimism and negative thinking that is an inherent part of depression will otherwise prevent the person continuing with treatment and following the advice of their doctor. The person who is depressed needs somebody to talk with about how they are feeling. They need to know that they are being heard and understood and they will benefit from firm reassurance that they will recover. Within this confiding relationship, they will also be able to explore losses and hurts and begin to go through the stages of grieving or start to address the factors that contributed to the depression.



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