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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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When someone we care for becomes ill we react as we do to any loss. Mood disorder is a temporary loss of the person we once knew. As with any loss we go through stages of shock or disbelief, searching for what is lost by showing care and concern, this is followed by anger or agitation, if the searching is unsuccessful. Despair or sadness and ultimately acceptance of the situation then follow. While the person who is ill may feel hurt by these reactions, it is important to realise that it is a normal and understandable reaction to loss, that if the situations were reversed they would react in a similar manner and that they should endeavour not to take it personally.

Both the person who is ill and relatives and friends need to understand how each reacts in these situations and how with a factual understanding of both mood disorders and one’s reactions to it, they can keep the relationship at a caring, supportive level until recovery is achieved. It is this well informed, caring and supportive approach that relatives can bring to the management team, and, so speed recovery and, equally importantly, prevent marital and family breakdown, unemployment, alcohol abuse, financial difficulties and even suicide.

Depressed Parent: Effect on Children Children are just as much affected by depression or elation as adults, if not even more so. They are particularly vulnerable to the negative impact of mood changes, as they are less able to take a detached view of what is happening and separate the mood-based behaviour from the person.

Although the child may know that there is something amiss at home, when they see a parent unable to go to work, or being admitted to hospital, they are all too frequently given little or no explanation and have to figure it out for themselves. Once a child is given a factual explanation about the parent’s depression or elation, in terms appropriate to their level of understanding, told what treatment is being prescribed and what the likely outcome is, they become less frightened. In the absence of this information, they will usually imagine that something more sinister is happening, such as their parent being terminally ill. A depressed parent may be withdrawn, negative in their outlook, or extremely critical, and all of this impacts on the children.

It is usually difficult for the well parent to stand back and separate the depression-related behaviour and not to react as if the ill parent had full control over matters. It is even more difficult for children; they can quickly absorb the depressed parent’s view of the world and of themselves. If in a depressed state, a parent is constantly finding fault with a child it will often result in the child having a similar negative self-image.

Children respond to a parent’s mood changes in a similar manner to adults by going through stages of initially being caring and supportive. They will nearly always take the lead from the well parent. If the well parent is supportive and understanding and has a positive attitude to the management of the mood problem, so too will children. Like adults, children will tend to cope with continuing illness or frequent relapses by becoming angry or depressed.

It is not unusual for the well parent to rely on the eldest child when their partner is unwell. While this may help both child and parent initially, it can result in adult type responsibilities being placed on the child, making them an adult before their time. It can have a detrimental effect on the parent’s relationship with each other, because as the depressed parent recovers they will often find that their position and role in the family, which has been taken over by the eldest child, is slow to be returned to them. So while openness about depression or elation is necessary to reduce the tendency of children to worry, it is important that they are not overburdened and that they are encouraged to enable the recovering parent to resume their role in the family once again.

Advice for Relatives and Friends

1. A mood disorder is an illness and it can impact enormously on the lives of family and friends. Inevitably your initial reaction will be a spontaneous one of shock, disbelief or anger. It is easy to get entangled in the emotional web that grows out of these emotional reactions. Remember that depression and bipolar disorder are illnesses; they have signs and symptoms and can be effectively treated. You must see it as an illness and not blame the person for their behaviour. This is not always easy to do, but the more you can do so, the more success you will have in maintaining your relationship and helping steer the person to recovery.

2. You are bonded to the person who is ill, so whatever affects them will impact on you emotionally. Consequently, and as you can do much to limit the negative impact of the mood disturbance, both on your own health and that of the person you care for, it is vital that you are available to help out on the management team.

3. Support the person unconditionally as they are ill. When you become familiar with the facts about mood disorder and its emotional impact, you will be best placed to deal with it.

4. Get as much information about depression and bipolar disorder as you can. Knowledge is power and the better understanding you have of the condition, the more you will feel in control of the situation. Lectures, audio and audio-visual tapes, and books are readily available on many different aspects of depression. In addition to learning the signs and symptoms and other facts about mood disorders, it is equally important to know how it makes you feel and react.

5. The most efficient way to treat a mood disorder is to have a three member management team, consisting of the person who is ill, one or several family members or a close friend and the treating doctor or therapist. This team should operate on a partnership basis, as each has an equally important role. Whether it is accurately assessing mood, reporting on progress between visits, providing ongoing support or preventing suicide, the team works best when the members genuinely listen to what each other is saying and value their respective points of view, as would any good partner.

6. It is not your fault that the person is depressed or has a mood disorder. Even if your relationship with the person is problematic, you did not choose that the person developed this illness, no more than they did. Sometimes you may blame yourself or be blamed, but anger, blame and guilt are usual reactions to illness. So do not feel guilty. If you are being blamed, do not take it personally, as it is the illness talking. Time and time again you will have to be objective and separate the person from the particular mood they are in and its effect on them.

7. Be aware of the emotional interactions that occur in mood disorder.

When you feel upset by remarks or behaviour, endeavour not to react with anger. Stop and analyse the situation and remember you are dealing with illness. The more objective you can be, the less entangled the situation will become.

Support group meetings for family members and friends are an ideal venue to both learn about the effects of the illness and to experience how you can deal with hurt feelings. It is not unusual for family members or friends to feel isolated and bewildered by the illness and their response to it. Meeting others who have had the same experiences and seeing how they cope with them effectively can be a real eye opener. Knowing the facts is not sufficient, so do avail of the opportunity to join a support group and learn at first hand how you can best deal with your feelings.

Just as you need a factual and emotional understanding of mood disorder, so does the person who is ill. Again, coming to terms with and understanding mood disorder is difficult for those who suffer from it. Support group meetings also provide an invaluable forum for people with the illness to meet others with the same difficulties.

In fact, those who have managed to avail of the enormous wealth of information, care and support that is available at these meetings are uplifted and quickly become equipped with the most efficient management strategies. It is vital that you encourage the person to attend these support groups, as they themselves, when ill, will find it hard to imagine the change that they can bring about.

8. Do not bottle up your feelings, as they will only lead to subdued hostility and a superficial and detached relationship. If you are upset by an event or a remark, it is best to first decide whether this was mood related, and if so, to ensure, as part of the partnership team, that this mood change is being tackled. It is also important to express your hurt at the appropriate time, but not in an accusatory manner. You should say how you feel, such as “I was hurt by what you said to me yesterday”, rather than retaliating by making hurtful remarks and dredging up similar episodes from the past. What you should endeavour to do is to help the person to limit their upsetting behaviour and to get them to accept responsibility for it, without blaming them. This type of intervention is usually successful in limiting the negative impact of depression. The person’s mood may not always allow this type of intervention to occur immediately. It is, however, vital that once the acute phase of illness has passed that you talk over the upsetting events, otherwise such situations are likely to recur, and eventually will have a progressively damaging effect on your relationship. Initially, it may be best to explore these difficulties in a joint meeting with the doctor. Also, support group meetings can be particularly effective in helping you decide how best to approach these delicate issues. It is also recommended that the person who is ill be encouraged to facilitate this form of nonjudgemental exchange of feelings, as it helps them sustain the relationship and does enable them to take responsibility for their behaviour, which in turn limits the likelihood of it recurring.

9. Almost all immediate relatives or close friends of an individual with a mood disorder will, as has already been mentioned, be emotionally affected. So do acknowledge your needs and get appropriate help.

Your first response should be to endeavour to keep up your routine of work, leisure and social outlets. Being well informed about the facts of mood disorder, learning how to address conflicts that are still arising and how to express your feelings about the illness through regular attendance at support group meetings and finally being part of the management team are the most significant steps in addressing the emotional implications of the illness.

Others are affected at a deeper level and may need to see a doctor or therapist, alone or jointly, on a number of occasions. Obtaining help for yourself is a sign of strength, not of weakness. Feelings are hidden out of fear and fear should be confronted.

10. Becoming part of the management team is one of the most significant contributors to recovery. If this team is functioning effectively, it will limit the duration of mood swings, reduce or prevent hospitalisations, reduce days missed from work and help limit the complications associated with mood disorder. It is essential that the person who is ill is well informed of the need to have a key relative or friend involved in management. Aware recommends that the person with the illness should choose a key individual, preferably their next of kin or at least somebody whom they are in regular contact, to join the management team. The person chosen must be somebody in whom they have confidence, whose judgement they trust and who is familiar with the factual and emotional aspects of the illness.

If there is a depressive relapse, the person who is ill is usually the first to realise that they are not well, but they may need prompting from a relative to seek help. However, in elation it is a family member who will usually first notice the upswing in mood, and, as such, they have a major role in spotting symptoms of mania. How this should be done, what particular symptoms should be watched for and how the observations should be communicated to the person, should be decided upon with the patient when their mood is stable. When elated the person may show varying degrees of resistance to this approach, but they will usually be thankful later for your timely intervention when they realise it prevented an admission to hospital or a reckless spending spree. The person with the illness will often need time to adjust to this form of intervention. For those with severe recurring mood disorder it is essential and often life saving. This often means that the person has to choose to trust you to help spot and prevent a significant relapse or else rely on their own ability to deal with an illness that can alter their judgement.

11. If the mood is disabling for more than a short period of time, you or some other family member may have to take over some of the person’s role in the family. This may range from doing the shopping for food or earning additional money. By agreement, you may have restricted access to money or to driving the car or be supervising medication. Whereas these interventions are useful at the time, there is an understandable tendency to be reluctant to hand back control to the person when their mood settles, particularly where there has been a prolonged mood change or frequent relapses. It is important to return these controls as soon as possible, as many find it hard to cope when separated from their usual lifestyle. This calls for flexibility which hopefully will in turn result in a readiness to reinstate these controls, should it become necessary in the future.

12. An immediate relative can feel shut off from the depressed person’s life because of illness and even more so when they are confiding their feelings to a doctor or therapist. This exclusion may cause resentment and a tendency to belittle the importance of the doctorpatient relationship. Having a relative actively involved in the management team prevents this sense of isolation.

The patient, on the other hand, may feel their privacy is being intruded upon when a relative is also seeing the doctor. It is quite feasible for you as a relative or friend to monitor the person’s mood, support them and report on progress without intruding on the personal issues about which they need to talk confidentially to the doctor. Monitoring of mood and its management can be separated from the counselling or psychotherapeutic aspect of the treatment plan.

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