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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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Psychotherapy: This is a more intense form of counselling and, in addition to being a support for the person during the time of distress, it also helps the development of an understanding of their symptoms as a response to current loss in the context of similar early life experiences. A particular form of psychotherapy called cognitive therapy, explores the validity of the negative thoughts that contributes to the feelings of depression and anxiety. By challenging these negative perceptions, alternative ways of looking at situations in life are developed, which in turn generate new solutions. Cognitive therapy is now considered to be an effective form of treatment for depression and it has been shown to be as effective as antidepressant medication. It does appear to have a role in preventing depressive relapses, but many patients find it difficult to apply when they are severely depressed. In these instances, it is best combined with antidepressant medication.

Antidepressant Medication: The most effective treatments for severe depression are antidepressant medications. They usually take at least 2 weeks before they begin to work, and once they have been effective they need to be continued or at least 4 months after the depression has lifted, as the depression is otherwise more likely to recur.

Antidepressants, unlike tranquillisers, are not habit forming. They are not effective where the person has emotional distress or a reactive depression, and should be reserved for people who have definite endogeneous features of depression. The older antidepressants introduced in the 1950’s and 1960’s such as Tryptizol, Anafranil, Surmontil and Prothiaden, are now being replaced by a newer generation of treatments with fewer side effects. The new antidepressants include Cipramil, Faverin, Edronax, Efexor, Lustral, Prozac, Seroxat and Zispin.

You will find further details on the different forms of these treatments listed under Suggestions for further reading, Mood stabilisers: Mood disorders by their very nature tend to be recurring and this is particularly so when the episode of depression is severe or if it is bipolar disorder. For recurring mood swings, preventative treatments are necessary and these are referred to as mood stabilising agents. Lithium remains the most frequently prescribed drug and is effective as a mood stabiliser in some 70% of cases when given alone or in combination with other agents. Where the mood swings are recurring very frequently, as in rapid cycling mood disorder, other treatments such as carbamazepine, sodium valporate or lamotrigine, are the preferred treatments.

Electro-convulsive Therapy: Electro-convulsive therapy (ECT) is an effective treatment for severe depressive illness, where there are depressive delusions or hallucinations or when other treatments fail. It is usually for depressions with biological or endogenous features, such as broken sleep pattern, early morning wakening, weight loss, morning worsening of symptoms, or slowing of mental and physical activity, that ECT is particularly effective.

The optimum treatment for any individual is decided upon after assessing their underlying personality, whether there is a family history of depression or related conditions, whether losses or upsets were experienced prior to the onset of the depression and determining the symptom profile of the mood disorder. While one form of treatment may be effective for a particular type of depression, it is more likely that a combination of antidepressant medication or mood stabilisers and some form of counselling or cognitive therapy will often be more effective.


Your Role as a Relative or Friend

Depressed people affect others:

Depression and elation are disturbances of emotion and as we are bonded to family and friends by emotion, mood disturbances inevitably affect relationships. For some immediate relatives the impact of an ongoing mood disturbance can be enormous. Surveys have shown that 40% of key relatives of people with depression are themselves sufficiently distressed to need help.

It is the ongoing worry, social withdrawal and irritability that most upsets families.

Even if this is not a worry for you right now, it is vital that you understand what happens in relationships during depression, so that you can minimise the disruptive effect it may have on you and your family’s lifestyle.

During a bout of depression or elation, the person’s perception of what their mood does to them, their family, and friends is often inaccurate. This perception can lead to the person feeling alone, isolated and misunderstood.

Inevitably, this will in turn disturb close relationships. It also leads to inaccurate reporting of the extent of their mood disturbance and its consequences to the doctor. It is essential that a close friend or relative work jointly with the person with the mood disorder and the doctor or therapist as part of the management team. This three stranded team approach ensures that the necessary care and support is in place to reduce the person’s sense of isolation, that the doctor gets to know the full extent of the mood disturbance and that any adverse effect of the illness is addressed early, and better still, prevented. Concerned family members or friends usually want to help and they have a particularly important part to play in aiding recovery and limiting the damaging effect of mood disturbance. Not infrequently, the person who is ill may feel they are an additional burden on their families in expecting them to help and be supportive in this way, or they may see it as relatives are usually of enormous assistance, provided that they understand the facts about the mood disorder, have the ability to listen and can accept what the person is experiencing, without feeling they are responsible for relieving this distress.

Family members often find it hard to understand why people when depressed get to work, hold down jobs, and even socialise, yet at home they are irritable and withdrawn. What is even more perplexing is that they can snap out of depression when vistors call to the house. This is a wellrecognised aspect of depression of a mild to moderate, or even a severe, degree. Not infrequently when someone is admitted to hospital with a severe depression they can appear to be perfectly well for the first few hours or days, but then the true picture of depression emerges. In other words, they can reflexively and unconsciously put on a bright face when they go to the doctor or socialise, but cannot sustain it. The mask shown to the world, other than close family, is barely affected in the early stages of depression.

A further significant reason for involving a key relative, particularly a spouse, is that there may be a poor marital relationship either preventing full recovery or contributing to, or being the main cause of, the depression.

Research has shown that where the well spouse is critical of the person with depression that a depressive relapse can be reliably predicted. In such instances, the impact of marital difficulties on the person may not be obvious to the doctor or therapist, as neither patient nor relative reports what is happening in their relationship, believing it to be irrelevant or that they are simply reluctant to address the matter as they see no ready solution. In addition, very often ongoing problems such as marital difficulties, financial problems or unresolved, prolonged grieving become so much part of the person’s life that they cannot necessarily see the effect it is having on their mood.

Finally, the constant train of altered perception, overly pessimistic in depression and unduly optimistic in elation, can have devastating consequences. In a depression a person feels isolated, unwanted, guiltridden, and useless, resulting in avoidance of family and friends, irritability, hostility, impulsive resignation from work, making reparation for imagined wrong doings and even suicide. In elation the exhilaration, enthusiasm, and confident grandiose behaviour tends to result in overbearing, demanding and insistent, even aggressive behaviour, which if unchecked, results in over spending, extra marital affairs, promiscuity, and engaging in business and other schemes, that are so ill judged, that they are bound to fail. A relative or friend is an essential ally when the person’s thinking is not as it should be. Enlisting the support of such an ally is invaluable in detecting a relapse of depression or elation at an early stage, and so being able to counter the excessively pessimistic or optimistic thinking that leads to so many difficulties. Early detection of a mood change prevents the person’s life from being scarred by the complications of mood disorder.

When this prevention programme is employed effectively, it means that once a person’s mood subsides they can continue with their lives, rather than having to untangle problems in so many different areas of their lives.

Why the divide?

Depression changes the way the person both feels and perceives themselves and the world about them. In addition to a negative perception of themselves, the person often has blunted feelings that give a sense of being shut off from the world, as if they were behind a glass wall. To counter this detached feeling, they will either cling to the person from whom they feel shut off or accuse them of being less affectionate. What the person doesn’t realise is that it is their own feelings that are blunted. All too often, this leads to marital friction. Complaining about their spouse is frequently the first symptom of depression. While the misperception will impact on any major relationship that the person has, it can also affect other facets of a person’s life: a teenager may become excessively preoccupied about their appearance, fear of having cancer or AIDS may predominate another’s thinking, and, for some, needless concern about money or taxation can be crippling. It is all too easy for family members or friends to become embroiled in a tangle of debate with the person who is depressed, without realising that the issues being discussed are based on the depressed mind’s misperceptions. Emotional withdrawal, clinging, irritability, and incessant worry about issues that have no basis in reality do take their toll on relationships. In depression, the focus of the mind may differ from person to person, but it is often the same issues that become a recurring concern when an individual has a depressive relapse.

Mania or elation can have an even greater and more obvious detrimental effect on relationships. In the high phase, the person is emotionally expansive, in contrast to the contracted state of depression. It is as if the person breaks the usual boundaries and in doing so disrupts the previously close, intimate relationships with immediate family and friends. More distant friends or work mates will not usually, at least initially, notice the change. The person becomes more attracted by the heightened sense of feeling of new situations and the ability to carefully weigh up situations is dominated by an overly positive attitude. What happens to judgement in elation is best understood by thinking of how we usually make a decision, such as buying a new coat. We ask ourselves do we need it, is it good value, will it wear well, will it match other colours and so on. The elated mind can only see the positive side and the counter balance negative side, such as that it is too expensive or that they purchased a new coat recently, is not considered. The reverse happens in depression, so that the coat is not purchased. The constant attractions that this heightened sense of awareness and overly positive view leads the person to stray from their commitments, values, and relationships. This inevitably places an enormous strain on previous stable and satisfactory relationships, without the person, and sometimes the immediate family, realising that they are in an ill, manic state. Alcohol, street drugs, teenage behaviour, personality of being easily “led astray” are often the reasons cited mistakenly by relatives for the person’s changed behaviour.

When depression or elation is not seen as an illness and when the person is blamed for their behaviour, it leads to a breakdown in communication, with marital disruption or alienation from the family. Even when the changed thinking, feeling and behaviour are seen by relatives as illness, the person will often have insufficient understanding and insight, and so may refuse to get help, shun the family and behave in a reckless manner or attempt suicide.

Changes in feeling and judgement of mood disorder will affect every close relationship, but to what degree, will depend on the severity of the illness, the promptness with which help is sought and the readiness to enlist the help of a close relative or friend.

How families react to mood disorder When a family first learns that one of its members is ill with depression or elation, after getting over the initial shock, they will search for a solution.

Usually this entails encouraging the person to get professional help. They will be supportive and show concern, want to know what the diagnosis is, what treatment has been recommended and when the person can expect to recover.

This caring, supportive approach will continue if the person recovers on schedule and remains well. However, if recovery is slow or there are several remissions and relapses, then care gives way to frustration. Subtle manifestations of this impatience with lack of progress are making suggestions to the person that they should exercise, diet or get a second opinion. The more forthright family members may have a “no nonsense” approach and will bluntly exhort the person to “pull up their socks” or “snap out of it”.

If, as time passes, these different forms of interventions by family and friends are proving ineffective, they begin to despair. This is evident in that a relative may no longer be making well-meaning suggestions, there is a tendency to enquire less often how the person is feeling, and the family member may begin to become detached emotionally from the illness. More blunt speaking relatives or friends may frankly say they do not want to hear about the symptoms.

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