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13. Both you and the person you care for should feel you can speak openly to the doctor about your concerns and know that these are being addressed. The person who has the mood disorder should feel cared for, have confidence in the treatment plan and you should, if requested, be able to get a second opinion.
14. When you visit the doctor, it is a good idea to have documented the person’s mood on a daily basis in the form of a graph (see page 31).
This is a valuable form of feedbeack for the doctor, especially when it is matched with one graphed independently by the person with the illness.
It is also useful to make a brief note of any concerns you have about the illness and its treatments to list these, so that you derive most benefit from the consultation.
15. Additional joint or family therapy may be necessary where there are marital difficulties, unresolved issues relating to emotional consequences of the illness or where there are conflicts regarding monitoring of mood.
16. Quite frequently the person who is depressed refuses to get help, as they see it as a sign of failure, that it will not work, that it will alter their relationship with you because they are in an angry frame of mind and see seeking help, as giving into you. Men in particular have a need to feel self-sufficient, they find it difficult to talk and tend to drink as a way of coping. You may consider this refusal to get help as a rejection, but do not take it personally. Pushing people away is a feature of depression. Identify whether it is having a diagnosis of depression, needing treatment or some other aspect that bothers them specifically. Talk about what you are feeling and the effect the illness is having on you. Present them with the problem of depression as something you would tackle jointly. For example if the person’s sleep disturbance keeps you awake at night, it is then a joint problem and can be presented as such to the person who may be willing to address it by talking with the doctor. They may be prepared to take the advice of somebody they know who has been treated for depression. It is useful to give literature about depression and be gently persistent in your approach. To highlight the level of your concern about the problem, it is useful to make an appointment to discuss the issue with them. Don’t be afraid to ask them to get help just to please you. If you consider that there is a risk of suicide or other behaviour that is likely to have a detrimental effect on the person with the illness or others, you have a responsibility to get that person help, as their judgement is impaired at that time. In some extreme instances this may mean that person has to be hospitalised involuntarily and this is something that you should discuss with your doctor. By applying the recommendations in this booklet, it is usually possible to reduce the need for admission to hospital, but when these recommendations are proving ineffective, because of the severity of the situation, it is important that you remain objective and remember that you are dealing with an illness.
17. Do not avoid bringing up the subject of suicide. If you sense the person’s hopelessness and despair, it is important to get them to talk about it. People often fear this will increase the risk of the person harming himself or herself. Most who are depressed will have thoughts in varying degrees about suicide, and having discussed it with you, it is often an enormous relief to them. What matters is how extensive are the suicidal thoughts. Has the person any intention of harming himself or herself, have they made a plan and do they have any hope. It is those who feel increasing hopelessness, that they are a burden on others or are unwanted, and cannot see an alternative, that are at serious suicide risk. It is essential that you get the person help and convey your views to the doctor or therapist.
18. Remember that depression and bipolar disorder are illnesses that can be effectively treated. You have an important role to play in ensuring that the person who is ill receives treatment, that they are supported and cared for until they recover and that the complications so commonly associated with mood disorders are prevented. It can be a difficult time in your life, but by following the guidelines set out in this booklet and providing unconditional support, you will be well placed to help the person recover and limit the disruptive effect of the illnes on both of your lives.
Figure A daily graph of mood made, separately and without comparing ratings, by the patient and relative is an invaluable record of mood, as it is often difficult otherwise to accurately report mood changes between consultations.
Both of you should make your separate records of the patient’s mood by making an ‘x’ on the graph just befor going to sleep at night. If you consider that the mood on the 4th April in the graph normal line at the 4th. On the 5th, if you consider the person was mildly depressed you make your mark ‘x’ across from -1 and down from the 5th.
A severe elation, that is an elation as bad as the person has ever experienced, is rated for the 6th of the month. The grades of mood changes are determined by what you both regard as mild, moderate and severe for the patient, so in this way it becomes an accurate reflection of the person’s mood. It is best to keep these records in separate copybooks, such as an ordinary A5 copy as you then have a safe record that you will not easily lose. You should bring these records with you each time you visit your doctor.
Glossary of Terms Biological Depression: This refers to depression with symptoms and signs such as weight loss, wakening repeatedly during the night or early in the morning, feeling worse in the morning, slowing of thinking and body movements and guilt feeling. This depression is called biological as the disruption it causes are to the biological functions of sleep, appetite, weight, and sex drive. Furthermore, it has been observed that depressions of this type tend to run in families or are known to be inherited. Therefore, they have a biological or chemical basis, rather than being primarily determined by environmental events. The term “biological” is often used interchangeably with “endogenous” - that is depression coming from within.
Bipolar Disorder: This is now the term used for manic depressive illness.
It refers to the two “bi” poles or aspects of the illness, namely mania and depression.
Bipolar I (BPII) Disorder: Where the more severe form of elation, namely mania, is present. This is defined as the presence of features of mania for at least one week and which is causing disruption. There may also be varying degrees of depression or the mania may be the only aspect of this form of mood disorder.
Bipolar II (BPII) Disorder: Where there is major depressive disorder and hypomania, which is the lesser degree of mania, lasting from 4-7 days, but is not severe enough to cause marked impairment in social or occupational functioning or to require hospitalisation.
Clinical Depression: Refers to the more prolonged and intense experience of depression than is encountered in normal depression, with which the person is having difficulty coping. “Clinical” means that it needs clinical or professional attention.
Cognitive Therapy: A type of talking therapy in which the person’s depression or anxiety is considered to arise from faulty negative thinking.
The therapy helps question the validity of the thinking, enables the development of more positive views, which in turn generates new solutions.
Delusions: False ideas that a person firmly believes in and cannot be changed by rational argument. In depression the delusions may be that the person has carried out some crime or they have cancer, when there is absolutely no evidence to support this. In mania, the delusions are usually grandiose in that they may believe that they are god-like or have miraculous healing or other extraordinary powers.
Depression: Both a symptom, when it refers to a dispirited feeling, and a condition or a diagnostic entity in which there is a reduction in mood, dulled thinking, sapped energy and loss of interest in work, food, sex and general every day activities and disrupted sleep.
DSM-IV: The Diagnostic and Statistical Manual - IV Edition (DSM-IV) is an agreed method of defining and classifying psychiatric disorders prepared by the American Psychiatric Association.
Dysphoric Mania or Mixed Episode: Refers to a mixture of manic and depressive symptoms occurring simultaneously, so that rather than feeling elated the person feels irritable, angry or depressed. It is probably best to consider it as a variant of mania, as it is usually obvious that the person is overactive, restless, overtalkative and requires little sleep and responds best to the treatment used for the elated form of the mania, rather than antidepressant medication.
Dysthymia: A form of low-grade depression, more intense than normal depression, but less than major depressive disorder, that lasts for at least 2 years. It usually starts in the late teens or childhood and may go on to develop into episodes of major depressive disorder.
Elation: This term is often used interchangeably with the word “mania”;
it is a general term to describe a happy or pleasant mania where the person feels euphoric, in contrast to the unpleasant dysphoric mood and is usually accompanied by overactivity, overtalkativeness, restlessness, reduced need for sleep and a sense of brimming over with energy and ideas.
Electro Convulsive Therapy (ECT): The application of an electrical charge to the anaesthetised patient’s head for a brief period to produce a minor seizure or fit. The latter is generally well controlled and barely perceptible, as muscle blocking agents are given with the anaesthesia. ECT is extremely effective in treating severe depression with biological features or for depressive delusions that are resistant to anti-depressant medication and other treatment. It is occasionally used for mania that is failing to respond to medication.
Endogeneous Depression: “Endogeneous” means generated within, to distinguish it from external or reactive depression. The term is used interchangeably with “biological” depression and its main features are a broken sleep pattern, early morning wakening, weight loss, feeling worse in the morning, guilt, slowing of thinking and body movements and an inability to be cheered by pleasant events.
Hallucination: A sensory experience of sound, vision, touch, smell or taste for which there is no objective stimulus or explanation. Most commonly it is experienced as hearing a noise or voices in the head, which the person perceives as not being their own thoughts. In depression it may be a voice telling the person that they are bad or evil, blaming them for wrong doings or telling them to harm themselves. In mania it may be a voice or vision or what the person perceives as God or a supernatural power or where they are being instructed to carry out a particular mission.
Hereditary or Genetic Factors: We inherit genes or genetic factors from our parents as coded chemical messages in the ovum and sperm. When these messages from our respective parents come together they instruct body cells to make certain chemicals, which determine our height, weight, hair colouring and other features. They also provide the chemical factors that determine the range of mood experience we are able to have.
Hormones: Chemical messengers produced by glands in the body. The ovary makes the sex hormones, oestrogen and progesterone, the testes generate testosterone and the adrenal gland produces adrenalin and steroids.
These hormones are released from the glands into the blood stream and are carried to different areas of the body where they regulate the function of the brain, the gut, the heart and so on.
Hypomania: This is a lesser degree of mania, where the person is persistently elated or irritable for at least 4 days and has at least 3 other symptoms, is not causing major impairment of functioning or likely to require hospitalisation.
Limbic System: This loosely refers to areas of the brain, such as the thalamus, hypothalamus, hypocampus and the temporal and frontal lobes and their interconnections. It is these complex interconnecting systems, much like a railway system linking train stations, that is involved in determining and regulating our emotions.
Lithium: This is a natural element which is quite like sodium and is found in soil. It has been shown to be effective in treating mood swings of recurring depression and bipolar disorder. It is also used in combination with anti-depressant medication to treat depression that is failing to respond to anti-depressant medication alone. The dosage of this treatment needs to be regulated carefully, as it is easy to be on too little and not receive its benefit, or be on too much and have toxic side effects. For this reason, it is necessary to do blood tests to measure the body’s concentration of Lithium when on this treatment.
Major Depressive Disorder: This is defined as the presence of 5 or more of the 9 common symptoms of depression for longer than 2 weeks. In addition, the symptoms are causing significant distress and are interfering with the person’s ability to fully function.
Mania: This is a speeded up, expansive state in which the person is overactive, overtalkative, restless, elated or irritable, grandiose, needs little sleep and is excessively pursuing pleasurable activities. To meet the usual criteria for mania, 4 or more of these symptoms need to be present for at least 1 week and to be causing marked disruption in someone’s occupation, social activities or relationships with others.
Manic Depression: Refers to depression of bipolar disorder or manic depressive illness where there is alternating episodes of depression and mania. As a term, manic depression or manic depressive illness has been replaced by “bipolar disorder”.
Mood Disorder: A disorder of feeling that is either depressed, as in depression or elevated as in mania.
Normal Depressions: Mild and short lived shifts in mood, often referred to as the ups and downs of every day life, or the Monday morning blues.
Normal depressions, by definition, are within our coping abilities and normally occur following some unexpected negative event.