3.1 Major depression

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3.1.1 Description and diagnosis

Description

Depression is a mood state that is characterised by significantly lowered mood and a loss of interest or pleasure in activities that are normally enjoyable. Such depressed mood is a common and normal experience in the population. However, a major depressive episode can be distinguished from this `normal' depression by its severity, persistence, duration, and the presence of characteristic symptoms (e.g., sleep disturbances). The most common emotional, behavioural, and physical symptoms of a major depressive episode are:

Common presentation

* Markedly depressed mood
* Loss of interest or enjoyment
* Reduced self-esteem and self-confidence
* Feelings of guilt and worthlessness
* Bleak and pessimistic views of the future
* Ideas or acts of self-harm or suicide
* Disturbed sleep
* Disturbed appetite
* Decreased libido
* Reduced energy leading to fatigue and diminished activity
* Reduced concentration and attention

The depressed mood is relatively constant from one day to the next, although the mood may vary somewhat during the course of the day. A pattern is often present in which mood becomes better as the day progresses.

Atypical presentation

There is substantial individual variation in the presentation of the disorder. In atypical presentations the following features are prominent:

* Mood is reactive such that mood brightens during positive events or in response to anticipated positive events.
* Two or more of the following features are present:
* Increased appetite or significant weight gain.
* Excessive sleepiness (at least 2 hours more than when not depressed).
* Heavy, leaden feelings in the arms or legs, often lasting for many hours at a time.
* The individual has a life long trait of being particularly sensitive to perceived interpersonal rejection to the point that functional impairment exists.

Atypical presentations tend to be associated with a younger age of onset of depressive disorder and are more common in women.

Subtypes of depression

The current classification systems for psychiatric disorders, namely ICD-10 (International Classification of Diseases, Tenth Revision) and DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition), describe major depression as a unitary syndrome; i.e., that major depression lies on a continuum which varies in severity and may be accompanied by psychotic and/or somatic (melancholic) features. These psychotic and somatic features are described later in this section. However, many experts in mood disorders argue that it is also useful to classify a separate subtype of depression that is distinguished by the presence of `somatic' or `biological' features. This subtype is referred to as melancholic depression or endogenous depression.

Research has indicated that the core feature of melancholic depression is marked physical slowness or agitation. Additionally, the individual cannot be cheered up by others and experiences a persistent inability to enjoy things. These features are important because of the implications for treatment. Physical treatments such as antidepressant medication, antipsychotic medication or electroconvulsive therapy (ECT) are the treatments of choice for melancholic depression.

Dysthymia

A milder but more persistent mood disorder termed `dysthymia' involves periods of years during which time the individual experiences a few, but not most, symptoms of major depression. Low mood or loss of interest must be present and delusions and hallucinations are absent. The individual could almost be regarded as having a depressive `personality style'.

While this disorder may interfere with social or occupational functioning, the disturbance is not severe enough to qualify for a diagnosis of major depressive disorder. Nevertheless, both ICD-10 and DSM-IV indicate that most individuals with dysthymia can experience comorbid major depressive episodes during the course of the dysthymic disorder, although DSM-IV requires that there have been no major depressive episodes during the initial two years of the disorder. Also, people with only partial recovery from a major depression are not classified as dysthymic.

Diagnosis

According to the World Health Organization's (WHO) International Classification of Diseases (ICD)-10th Edition, a diagnosis of major depressive episode requires the following criteria to be met:

* The presence of a minimum number of symptoms (see ICD-10 for details).
* Symptoms must be present for at least two weeks, unless symptoms are particularly severe or of rapid onset.
* The individual has never experienced manic or hypomanic symptoms severe enough to meet criteria for a hypomanic or manic episode (see p. 196).
* The episode is not due to psychoactive substance abuse or any organic mental disorder.

For a diagnosis of dysthymia the following criteria must be met:

* Depressive symptoms must be present for at least two years with no intervening periods of normal mood lasting longer than a few weeks.
* The individual has not experienced any episodes of hypomania.
* None, or very few, of the depressive episodes within the two year period have been severe or lengthy enough to meet criteria for recurrent mild depressive disorder.

For further details about diagnostic criteria for a major depressive episode or dysthymia, please refer to ICD-10 or DSM-IV.

Coding depressive features

According to ICD-10, major depression can be coded according to severity, psychotic features, and somatic (melancholic) features.

Severity of depression

The severity of depression can be classified as mild, moderate, or severe.

In mild depression the individual has some symptoms of depression and extra effort is required to do the things that need to be done. Mild depression is usually associated with only minor impairment in occupational or social functioning.

Moderate depression involves occupational or social impairment which is midway between the impairment associated with mild and severe depression. The individual has many symptoms of depression that often keep him or her from doing things that need to be done.

Severe depression involves marked impairment in these areas and may include psychotic symptoms. The individual has nearly all of the symptoms of depression and the depression almost always keeps the individual from doing his or her regular day-to-day activities. Somatic features are nearly always present (see the description on the following page).

Presence of psychotic symptoms

Severe depression may also be classified according to the presence or absence of psychotic symptoms. These symptoms include:

* Hallucinations (i.e., seeing, hearing, smelling, sensing, or tasting things that other people do not see, hear, smell, sense, or taste; for example, the person may hear voices which command him or her to behave in certain ways).
* Delusions (i.e., false beliefs that are firmly held despite objective and contradictory evidence, and despite the fact that other members of the culture do not share the same beliefs; for example, the person may believe that he or she is Jesus Christ, or that he or she is being followed, poisoned, or experimented upon).

On some occasions the hallucinations and delusions are in keeping with the individual's mood (mood-congruent), and at other times the hallucinations and delusions do not reflect the individual's mood (mood-incongruent).

Examples of mood congruent delusions involve themes of: guilt, deserved punishment, impending disaster, or bodily disease. For example, the individual may believe that the world is about to end or that people, even strangers, are plotting to punish the individual because they know that he or she has sinned greatly. Mood-congruent hallucinations typically involve hearing derogatory or condemnatory voices.

Mood-incongruent delusions or hallucinations involve false beliefs or sensations which are lacking in depressive or self-punishing content. For example, individuals may believe that they are being controlled by others, or that their thoughts are being broadcast to the world, or that people are talking about them and plotting against them (but not for reason of punishment or because they are sinners). Hallucinations may involve hearing voices that make comments which are not depressive or judgmental in nature.

The psychotic symptoms of a psychotic depressive disorder usually recur in subsequent episodes, should such episodes occur.

Presence of somatic features

According to ICD-10, for a diagnosis of major depression with somatic features, the individual must display at least four of the following symptoms:

* Marked loss of interest or pleasure in activities that are normally pleasurable
* Lack of emotional reaction to events or activities that normally produce an emotional response
* Waking in the morning 2 hours or more before the usual time
* Depression is worse in the morning
* Marked psychomotor retardation or agitation (observed by other people)
* Marked loss of appetite
* Weight loss (5% or more of body weight in the past month)
* Marked loss of libido

It is unclear whether somatic symptoms reappear from one episode to the next, however, they do seem to be more common among older depressed populations or among people who have a family history of severe depression. ICD-10 refers to these somatic symptoms as the `somatic syndrome'. DSM-IV uses the term `melancholic features', and the terms `endogenous' and `biological' depression have also been used.

Seasonal pattern of depression

Some individuals have a clear history of a majority of their depressive episodes starting and stopping at a particular time of the year (unrelated to seasonal employment). Most commonly, depression starts in the late autumn and often lifts in the spring. Although sometimes this a called `seasonal affective disorder', this is more properly termed major depressive disorder with seasonal pattern.

Differential diagnosis

A major depressive episode should not be diagnosed if organic factors such as infectious disease, drug use, or hypothyroidism caused or maintained the disorder. Individuals with a possible depressive episode will need a medical investigation to exclude organic cause.

Some individuals who are experiencing bereavement present with symptoms that are characteristic of a depressive episode (e.g., sleep and appetite disturbances, extreme sadness, etc.). ICD-10 does not classify bereavement as a mental disorder although recommends that bereavement that remains intense, lasts longer than six months, and is considered to be abnormal in some way would be classified as a sub-category of adjustment disorder. DSM-IV specifies that if the symptoms are present two months after the loss of the loved one, a diagnosis of major depressive disorder should be made. However, DSM-IV also recommends that the presence of the following symptoms may help to differentiate major depression from bereavement: guilt that is not related to actions taken (or not taken) at the time of the loved one's death; thoughts about death that are not related to the feeling that the individual would be better off dead or should have died with his or her loved one; intense feelings of worthlessness; prominent psychomotor retardation; prominent and prolonged impairment of functioning; and hallucinations that do not involve hearing or seeing the deceased person. Information about the management of bereavement is contained in Chapter 4.

Schizophrenia is frequently associated with comorbid depression. Similarly, schizoaffective disorder also involves episodes of depression. However, in depression, psychotic features never occur in the absence of depressive symptoms (as they do in both schizoaffective disorder and schizophrenia).

Bipolar disorder usually involves episodes of both mania and depression. If the individual has ever experienced a manic or hypomanic episode at any time, major depressive disorder should not be diagnosed. If the individual is over 65 years of age the presenting features of depression may need to be differentiated from dementia.

Epidemiology

The lifetime risk of having an episode of major depression is approximately 12% for men and 25% for women. Onset may occur at any time during the lifespan, with the most common age of onset being the late teens and twenties.

Course and prognosis

Major depression is both episodic and can be forever. The average duration of an untreated episode is 12 weeks, but many people have episodes that end after 4-6 weeks during which they have the full range of symptoms and are disabled. Some people, perhaps 10%, never recover without treatment. Half have an episode most years and too many suffer symptoms much of the time. Untreated, depression is episodic and chronic. Treatment should be long term.

With appropriate treatment, the majority of individuals will experience a complete recovery from the current episode. However, some individuals will require more intensive and lengthy treatment. The term `treatment resistant depression' has sometimes been used to define a depressive episode that fails to respond to a standard course of antidepressants or electroconvulsive therapy (ECT). The term has, however, been criticised as being merely a labelling phenomenon by clinicians rather than a useful diagnostic term. It has been pointed out that most definitions of treatment resistant depression:

1. Do not take into account depressive subtypes that are relevant for the particular treatment that is likely to be most effective.
2. Do not make a distinction between resistance to treatment, chronicity of the depression, and/or relapse or recurrence of a depressive episode.
3. Do not take into account psychosocial factors that may be maintaining the depression.
4. Do not include whether or not the individual has received an `adequate' course of psychotherapy (whether it be cognitive-behavioural, marital, family therapy, or other).

3.1.2 Assessment

The assessment of major depression will involve both a psychiatric assessment and a general medical assessment. Ideally, assessment of symptoms will occur not only at the beginning of treatment but should be repeated at appropriate points during treatment and at the conclusion of treatment. In this way progress can be measured and the management plan can be adapted accordingly. Some planned interventions may not bring about change in the individual and will need to be reviewed.

Psychiatric assessment

The aim of psychiatric assessment is to:

1. Identify the main diagnosis and any other comorbid disorders or problems.
2. Assess suicide risk (see Chapter 1: Core Management Skills)
3. Highlight the areas that require intervention (e.g., depressed mood, inactivity) so that goals can be set and a management plan can be devised.
4. Identify a baseline against which improvement or deterioration can be measured.

A psychiatric history and mental state examination (see Chapter 1: Core Management Skills) are standard components of assessment for all psychiatric disorders. In addition, the following assessment procedures will also be useful.

Symptom Checklist

Depressive symptoms may be grouped into three classes: physical; cognitive; and behavioural symptoms. Each symptom class requires emphasis on different forms of treatment. By determining the types of symptoms that are most prominent, treatments can be targeted more appropriately. A checklist, to be administered by the clinician, is provided in Section 3.4.1.

This checklist may be helpful if used regularly throughout treatment. There is evidence to suggest that symptom groups tend to remit at different times during the recovery process. Appetite and sleep tend to improve first, behaviour second, while thoughts and feelings tend to improve last. By identifying these changes in the depressed individual, progress may be monitored more closely.

Depression Anxiety Stress Scales (DASS)

The 42-item scale developed by Lovibond and Lovibond is a reliable and valid self-report inventory that provides three factor scores corresponding to depression, anxiety and stress. The three factor scores are psychometrically distinct _ DASS-Depression is characterised by depressed mood, low self-esteem and a sense of hopelessness; the DASS-Anxiety factor is characterised by autonomic arousal and fearfulness; And DASS-Stress is characterised by persistent tension, irritability and a low threshold for becoming upset or frustrated. In terms of the DASS-Depression factor, a score of 0-9 lies within the normal range, 10-12 mild depression, 13-19 moderate depression, 20-26 severe depression, and 27-42 extremely severe depression. However, all diagnostic decisions need to be backed up by expert clinical interview. Unlike the more widely used Beck Depression Inventory or Beck Anxiety Inventory, which are copyright, the DASS can be used without cost. The DASS is reproduced in Section 3.4.2.

Beck Depression Inventory (BDI)

The BDI is a widely used assessment instrument that measures the severity of depression. This instrument should not be used to diagnose depression. The scale consists of 21 items relating to symptoms and attitudes where each item can be rated from 0-3 in terms of intensity. The BDI was designed as an interviewer-administered scale but is now more widely used as a self-administered scale. The BDI is copyright and may be purchased from The Psychological Corporation, Locked Bag 16, Marrickville, NSW, Australia, 2204. Telephone (02) 9517 8999 or Fax (02) 9517 2249.

General Medical Assessment

A medical assessment is important for excluding possible organic causes (e.g., hypothyroidism) and for determining the individual's suitability for medication.

Comorbid mental disorders

Individuals with major depression will often be suffering from another non-mood mental condition such as an anxiety disorder. The diagnostic picture is usually clarified somewhat after the individual receives treatment for one of the existing disorders. However, it is not always easy to determine which disorder should be treated first. If the depression is not obviously secondary to another mental disorder, the flowchart on the following page will help clinicians decide when to treat depression in the presence of a concurrent non-mood psychiatric condition

Relationship between major depression and other current psychiatric disorders

Depression

1. When depression is treated the anxiety disorder should resolve as well.
2. Choose medications known to be effective for both the depressions and the other psychiatric disorder
3. Primary is the most severe, longest standing by history or the one that runs in the patients family
4. In certain cases (based on history), both major depression and substance abuse may require simultaneous treatment

Reprinted with permission from Depression Guideline Panel. Depression in Primary Care: Volume 3. Detection and Diagnosis Clinical Practice Guideline. Number 5. MD US Dept of Health and Human Services Public Health Agency, Agency for Health Care Policy and Reseach.

3.1.3 Management plan

The management plan will vary from one individual to the next depending on the individual's particular needs. Generally, however, the main aims of treatment are:

1. To conduct a thorough psychiatric and medical assessment (Section 3.1.2)

* (including suicide assessment, see Chapter 1: Core Management Skills)

2. To eliminate depressed mood and associated depressive features (Sections 3.1.5 and 3.1.7) through:

* Physical treatments and/or
* Psychotherapy

3. To provide education and support for the individual and family (Section 3.1.6)

4. To reduce residual problems (see Section 3.1.8) using strategies such as:

* Structured problem solving
* Improving sleep
* Increasing activity
* Encouraging eating behaviours
* Relaxation training
* Assertiveness and clear communication

5. To prevent relapse or recurrence of depression (Section 3.1.9)

The management of treatment resistant depression

Individuals who have not responded to an adequate course of antidepressant therapy or psychotherapy will require expert consultation. According to the Mood Disorders Unit at Prince Henry Hospital, Sydney, this consultation involves undertaking a detailed diagnostic assessment before any further treatment is started. The detailed assessment aims to:

1. Confirm the diagnosis. It is important to:

* Exclude alternative primary diagnoses such as panic disorder, dementia, schizophrenia, substance abuse, or organic disorders.
* Determine whether a depressive subtype exists (e.g., whether the depressive episode is melancholic in nature)

2. Fully assess psychosocial factors. For example:

* Are there problems with assertiveness or anger?
* Has there been an unresolved loss, or marital or family dysfunction, or another ongoing stressor that requires specific intervention?

3. Assess the individual's (and the doctor's) understanding of treatment expectations. For example:

* If the individual's premorbid personality was dysfunctional then expectations of a full recovery (to a state better than was experienced prior to the onset of the depressive episode) is unrealistic.

* If the individual's and/or the doctor's model of depression is totally biological then psychotherapy may not have been offered, or the offer may have been refused.

4. Assess all previous treatments and their appropriateness.

The management plan is therefore tailored for each individual based on this thorough assessment and on a reformulation of the individual's treatment goals.

Flowchart of management plan

3.1.4 Where to treat
Most people prefer not to go to hospital when they are depressed. Hence, whenever possible, unnecessary hospital admissions are to be avoided. In community mental health the development of extended hours teams, crisis teams, and other intensive treatment programmes have made less restrictive treatment options more viable.

In some instances, however, hospitalisation will be both necessary and beneficial. Most mental health acts recognise that an individual who is mentally ill needs to be protected from serious physical or financial harm and from harm to his or her reputation. Additionally, it is recognised that the individual needs to be prevented from causing serious physical harm to others.

The box below outlines some important issues to consider in relation to involuntary hospital admission. Where appropriate, the individual may be detained involuntarily for up to three days, and longer periods of hospitalisation can sometimes be organised following a Magistrate's hearing.

Assessing the need for hospital admission

Risk of intentional harm to self or others

* Has the individual expressed the intention to cause harm to self or others? (If threats have been made to harm another person, clinicians have a duty to warn that person about the nature of the threats).
* Is the intention to cause harm related to psychotic thinking? (e.g., hallucinatory voices commanding the individual to act in this way).
* Does the individual have a plan of action?
* Does the individual have access to dangerous weapons? (e.g., guns, knives, poisons and other drugs, a car).
* Has the individual attempted suicide or harmed others in the past?
* Does the individual live alone or unsupervised? Is there evidence of impulsive behaviour (now or in the past)?
* Does the patient abuse amphetamines, alcohol or other substances?

Other considerations

* Is the individual living alone and too ill for adequate self-care?
* Is 24-hour assistance available? (Consider family, friends, crisis team, GP).
* Does the individual live too far away to attend for outpatient treatment?
* Does self-harm arise in the context of personality disorder (particularly borderline personality disorder), in which case hospitalisation may be counter-therapeutic.
* Hospital admission may be necessary if the psychiatric diagnosis is unclear or if electroconvulsive therapy (ECT) is needed.

3.1.5 Eliminating depressed mood

The essential features of the management of depression involve physical treatments and/or psychotherapy. Physical treatments involve the administration of psychotropic medication or electroconvulsive therapy, although such treatments are not necessary for all cases of depression. Psychotherapy includes cognitive, behavioural, or interpersonal therapy. A psychotherapy component is usually always recommended for mild to moderate depression. Severe depression is also an indication for psychotherapy, although this therapy may need to be provided at a later stage of treatment once the depressed mood has lifted somewhat and the individual's concentration and comprehension abilities have returned. Further information about these strategies is contained on the following pages.

Physical treatments

The choice of physical treatments for acute symptoms of depression is based on a number of factors but is best made in consultation with specialist psychiatric opinion and in collaboration with the depressed individual and his or her family. Some of the options for physical treatment of this disorder are outlined below.

Medication

For some individuals, antidepressant medication will be the first line of treatment for the elimination of depressed mood. The table below shows the various classes of antidepressant medication, and the available drugs within each class.

Generally, medication may be prescribed if the following indicators are present:

* The depression is severe or recurrent
* Somatic (melancholic) or Psychotic symptoms are present
* Suicidal ideas are present
* The individual has had a previous positive response to medication
* There is a family history of affective illness
* The individual has failed to respond to psychotherapy

The absence of these indicators does not necessarily preclude the use of medication.

Antidepressant medications for primary care

The recognition of somatic (melancholic), psychotic, atypical features or seasonal pattern (see Section 3.1.1) may be helpful for guiding treatment choices. Depressed individuals who display somatic features tend to have a good response to antidepressant medication. If psychotic symptoms are also present, the combination of tricyclic antidepressants with either antipsychotic medication or electroconvulsive therapy (ECT) is superior to antidepressants alone in treating the disorder. Hospital treatment is generally required in such cases. Mild depression with a seasonal pattern often responds to light therapy, and SSRIs.

One of the problems with medication is that it takes a while (1-2 weeks) to produce a substantial improvement in depressed mood, and the full benefit may take up to 4-8 weeks to develop. The risk of suicide may be high during this lag period because the individual is still depressed but has greater activity levels and is therefore more able to carry out suicidal plans. Therefore, ongoing suicide assessment will be required during this period.

While medication is useful for relieving current symptoms of depression, it does little to prevent relapse or recurrence unless taken for indefinite periods of time. Patients who have had two or more significant major depressive episodes are now being encouraged to continue treatment for a number of years to prevent recurrence. However, some individuals do not wish to be on long term medication.

For further information about medication for depression, see Medication in Chapter 2.

Electroconvulsive therapy (ECT)

ECT is the most effective form of treatment for depression when psychotic symptoms are present. ECT is also highly effective for depression that is associated with somatic (melancholic) symptoms. ECT may be useful if:

* Psychotic symptoms are present
* Somatic (melancholic) symptoms are present
* The individual has had a previous positive response to ECT
* The individual has experienced treatment failure following several medications or combined medication and psychotherapy treatment trials
* There is a need for a rapid improvement of suicidal wish or refusal to eat
* There are medical contraindications to medication
* In pregnancy - ECT is safer than antidepressants

ECT involves the application of a brief electric current to carefully selected sites on the scalp. These electric currents, which are administered by a suitably trained doctor and an anaesthetist, produce a minor seizure in the brain and body. Prior to the procedure the individual is given a short-acting anaesthetic and a muscle relaxant.

Although many lay-people are sceptical and fearful of ECT, this technique is arguably the safest and most effective medical treatment for depression. ECT is more rapid in its effect than antidepressant drugs although antidepressants are a useful adjunct to treatment since they can help prevent relapse after ECT is completed. While ECT is a useful form of treatment, no-one fully understands why this technique is so effective.

For ECT to be effective the treatment needs to be repeated a number of times. The common treatment range is 4-15 treatments. Treatments are usually administered two or three times per week. Inpatient treatment is generally required although some individuals can be treated as outpatients or day patients. The most common side effects associated with ECT are: headaches, confusion, and short periods of memory loss or disruption. There is no evidence for any long term residual effects.

Psychotherapy

Psychotherapy is a useful treatment for depression. The majority of individuals will benefit from psychotherapy, even if their treatment also involves the use of physical therapies such as medication and ECT.

Psychotherapy may be useful if:

* The individual has had a prior positive response to psychotherapy.
* A competent, trained clinician who has expertise in psychotherapy is available.
* There is a medical contraindication to taking medications.
* The depressed individual prefers psychotherapy and his or her depression is not severe and not with psychotic features.

In most cases, psychotherapies that target depressive symptoms (cognitive or behavioural therapies) or that target specific interpersonal or current psychosocial problems related to the depression (interpersonal psychotherapy) are more similar than different in their effectiveness, with over 50% of depressed individuals treated with psychotherapy alone getting better. Although more than 200 other forms of psychotherapy have been described, these other forms of psychotherapy have not been subject to controlled treatment trials or they have been shown to be less effective than those psychotherapies mentioned above. All psychotherapies with proven effectiveness tend to: be time-limited; focus on current problems; and aim at symptom resolution rather than personality change as the initial target.

The use of cognitive, behavioural and interpersonal psychotherapy with depressed individuals requires competent clinicians who are experienced and trained in these approaches.

Cognitive therapy

Individuals who are depressed typically think that their problems will persist forever. If they are unsuccessful in one area of life they tend to generalise and tell themselves that they are hopeless in all areas of life. When something bad happens to depressed people they blame themselves, but when good things happen they tell themselves they are just lucky. Furthermore, depressed people are less likely to recognise and appreciate positive events when they happen; rather, they tend to be more tuned in to the bad things in their lives and brood over those events.

The aim of cognitive therapy is to help individuals identify and correct their distorted and negatively-biased thoughts. Underlying assumptions and beliefs are identified and challenged. By encouraging individuals to reframe the way they think about life, they are able to bounce back from failures more effectively and to recognise and take credit for the good things in their lives. Individuals learn that they have some control over what happens to them. One of the advantages of this form of treatment for depression is that, once acquired, individuals have these skills for life. Therefore, relapse and recurrence of depression may be reduced.

Behavioural therapy

Depressed people tend to have trouble motivating themselves. They often sit and ruminate for hours over their problems and miss out on opportunities that may be rewarding. Behaviour therapy aims to identify and change aspects of behaviour that may be implicated in the cause and maintenance of depression. Some forms of intervention involved in behaviour therapy include: activity scheduling, social skills training, structured problem solving, and goal planning. As with cognitive therapy, these new behavioural styles can be applied throughout life and hence can help to minimise relapse or recurrence of depression.

Interpersonal therapy

Interpersonal therapy (IPT) aims to clarify and resolve one or more interpersonal difficulties that are thought to either cause or maintain depression. These difficulties include: role disputes, social skills deficits, prolonged grief reactions, or role transition. Like cognitive therapy, IPT builds skills, but in the communication and interpersonal domians.

3.1.6 Education

Education for mentally ill individuals and their families or carers is an extremely valuable feature of all good management programmes. If the individual does not understand his or her disorder and associated treatment it will be very difficult to manage the disorder effectively. Education provides a knowledge base that potentially gives the individual greater control over the disorder. Greater control in turn may lead to reduced feelings of helplessness and an increased sense of well-being and good health.

Goal of education

The main goal of education is to facilitate understanding about the disorder and its management as relevant to each individual.

Integrating education into time-limited treatment
The guidelines for conducting educational sessions (following) covers detailed interventions. When time is limited, at least two periods of 10 minutes should be spent on `basic education' as described below. The first 10 minute session, explaining the diagnosis and treatment options, should be done at the time of diagnosis or within one week. The second session, reviewing treatment goals and relapse, should be at two months into treatment, when non-compliance often peaks.

Basic education

In particular, the following information will be important:

* Depression is an illness, not a sign of weakness or a character defect.
* Recovery is the rule, not the exception.
* Treatment is effective and there are many treatment options available. There is a suitable treatment for almost every person.
* The goal of treatment is to get well (100%) and stay well.
* The rate of recurrence is quite high: 50% of people who have had one episode of depression will relapse, 70% of people who have had 2 episodes will relapse, and 90% of people who have had 3 episodes will relapse.
* The individual and his or her family can be taught to recognise early warning signs of depression. By seeking early treatment after recognising these warning signs, the severity of the episode may be greatly reduced.
* An information sheet with the following messages has been shown to greatly increase compliance to medication.

1. Take the medication daily.

2. Don't stop the medication without calling me. If you have any questions call _________

3. Side effects lessen as your body adjusts. Call me if the side effects are unreasonable.

4. Expect a delay of 2-3 weeks before you feel better.

5. Don't stop the medication when you feel better, or your depression may return.

It may also be helpful to provide information about the following issues:

* The nature and prognosis of the disorder (Sections 3.1.1 and 3.4.3)
* Treatment options (i.e., psychotherapy, medication, or ECT) and relevant information about each alternative (e.g., side effects, duration, costs).
* Recognising and acting upon early warning signs (pp. 187-189)

During the education sessions individuals are encouraged to ask questions and to become actively involved in the management of their disorder. By doing so it is hoped that individuals will learn to control their disorder more effectively thus reducing disruption and suffering to themselves and their families. In addition, by involving families in the education sessions it is intended that families will be better able to understand their relative's illness and thus offer greater levels of support and assistance.

Guidelines for conducting education sessions

This section describes detailed `psycho-education'. While research interventions often feature multiple sessions, an alternative but detailed education strategy involves one session of 45 minutes for the individual and family together, covering the topics listed below. After the first long session, handouts and/or videos could be used to reinforce the message. A short second session should be held around two months into treatment. Clinicans are encouraged to use www.crufadclinic.org web based lessons to complement their patient education sessions

Adequate preparation for education sessions

Prior to conducting education sessions it will be important to undertake a thorough assessment of the individual's current knowledge, beliefs, attitudes, and expectations regarding the disorder and its treatment. Much of this information can be gained through the use of an Individual Family Member Interview such as the one developed by Ian Falloon (see Chapter 5: Schizophrenic Disorders).

A detailed understanding of the way in which the individual (and his or her family) views the disorder and its treatment can help educational material be targeted more appropriately. Generally, individuals will already have developed their own views of their experiences and the disorder. It will be important to assess existing beliefs before trying to teach a contradictory model that individuals may find difficult to accept. In addition, interviewing family members individually allows the clinician to develop rapport with each member of the family.

On a more practical level, clinicians also need to be fully informed about the severity of the individual's disorder, including such information as; current or previous medication; side effects of medications; previous psychosocial treatments; and effectiveness of previous treatments (medical and psychosocial). It will also be important to identify mental health problems among other family members. Affective illnesses tend to run in families so it is especially important to identify family members who have similar problems and to provide all family members with accurate information about affective illness.

When to provide education

The main educational input usually takes place over a number of sessions during the early stages of recovery after an episode of illness when the individual's concentration has improved. It is important that education be seen as an ongoing process that is updated as required. Research has shown that short-term education programmes tend to produce short-term benefits.

Level of material

Information should be kept simple and tailored to the audience (e.g., their level of education and comprehension, and prior knowledge of the disorder). It will be important to discuss issues in everyday language. Avoid unnecessary technical detail, medical jargon, or complex explanations. Avoid debates or arguments. Do not try to impress the audience with unnecessary scientific jargon. If clinicians are unable to answer a particular question, they can say that they don't know but that they prepared to consult experts and answer the question at the next session.

Handouts

* Prepare and review all planned handouts.
* Ensure that handouts are consistent with the information to be imparted and that they are written in a style that the individual will comprehend.
* Take care in recommending professional materials such as books or journal articles. These materials are seldom written in a way that can be easily understood by the lay-person and may only serve to confuse the issues. If particular books are to be recommended, it is useful if the clinician has read the book so that he or she knows what is being recommended.

Maintaining attention

* Present each point in no more than five minute segments.
* Encourage the individual to describe his or her own experiences, voice concerns, and ask questions. During family sessions, all family members need to be given an opportunity to participate.
* Encourage the individual to summarise the key points he or she has understood at the end of each segment. For example, "We have discussed the main symptoms of depression. Can you explain to me what you have understood these symptoms to be. You can refer to your handout if you like." During family sessions, involve all participants by directing questions at them in turn throughout the session.
* Repeat important points throughout the session.

Between session tasks

* Encourage the individual to read all handouts and make a note of any questions or concerns that arise during the time between sessions.
* Encourage the individual to seek out additional information from self-help groups, libraries, etc., and to bring this information in for discussion.
* For family education sessions it is useful to ask family members to discuss the material covered in education sessions outside of these sessions, perhaps at a specially arranged family meeting.

Review of information at the next session

* Begin the next session with a review of information discussed in the last session. Ask questions to assess understanding.
* Go over important issues that have not been clearly understood.

Content of education sessions

The most essential piece of information for an individual with a major depressive episode is that depression is a common disorder and that effective treatments are available. Major depressive disorder is probably best regarded as a biological disorder that can be influenced by life stress. The handout in Section 3.4.3 covers some basic information about depression.

Family education

When a family member becomes depressed, each family (and each family member) will react differently. The clinician can play an important role by fostering helpful and supportive family behaviour and by ensuring all family members understand what is going on. Family members, partners, and other significant people may need to be reminded that depression is not weakness or laziness. Individuals with depression have to cope with symptoms that have a major effect on their thinking, feeling, and everyday functioning. Individuals who are depressed will often become inactive and will appear apathetic and unmotivated.

In addition, families will often have to deal with the persistent hopelessness and despair of the depressed individual. There is also the added possibility that the family's attempts to help may be rejected or at least not acknowledged. The following positions may be experienced by family members who are living with a depressed individual:

* Family disregard or playing down of the signs of depression
* Rationalising the depression ("She's just run down at the moment")
* Denial ("It couldn't happen in our family")
* Guilt ("What have I done wrong")
* Anger ("Why are you acting like this!?")

It will be important to include the family in some or all of the education sessions so that they can discuss their thoughts and feelings and understand more about why their relative's emotions and behaviours have changed so much.

Medical treatments

The provision of clear information about the benefits and drawbacks of medication is an important component for encouraging adherence to medication. A large part of this information will be given to the individual by his or her general practitioner or psychiatrist. In practice, however, the individual may sometimes need to be reminded about various issues associated with medication, or may request further information. Although it is not the community mental health worker's job to be an expert in all aspects of medical treatment, some knowledge of such treatments is strongly advised.

Basic issues associated with medication are covered in Physical Treatments on page 173. More detailed information for clinicians can be found in Chapter 2: Medication. Some important educational aspects to consider with regard to medication include:

* Types of medication that are used for treating depression (i.e., antidepressants and antipsychotics)
* The benefits of medication
* How long medication is usually continued
* Side effects and other drawbacks of medication (e.g., reminder of illness)
* Strategies for minimising side effects
* Strategies for improving adherence to medication if long term treatment is required (see Chapter 1: Core Management Skills).

It will be important to elicit any fears or misconceptions held by individuals or their families about medication. For example, they may believe that the drugs are addictive, or that taking drugs is a sign of weakness. For more detail about medical treatments the individual may need to be referred to his or her general practitioner or psychiatrist.

Dealing with somatic complaints

If physical or somatic symptoms are present it will be important to discuss the link between these physical symptoms and the individual's mood. For example, individuals who are depressed are more likely to focus on sensations of pain. Normal aches and pains that would otherwise go unnoticed suddenly become very obvious. Effectively the individual's pain threshold is lower than usual. (See also Section 4.11: Unexplained Somatic Complaints in Chapter 4). However, depressed individuals have higher rares of physical illness than the mentally well, and it is important to exclude a concurrent physical disorder.

3.1.7 Dealing with depressive thinking

Individuals who are depressed will usually show a style of thinking that focuses on negative views of the world: for example, individuals may have a negative view of themselves as individuals, of their experiences, and of their future. They will come to think of themselves as worthless and of the world as being a bad or unfair place, without hope of their lives improving in the future.

As mentioned previously on page 175, cognitive therapy is aimed at reframing such forms of thinking and is therefore one of the most important components of management for depression. Unless a clinician has had specialist training in the delivery of cognitive therapy, referral will be required. However, the following points will be useful for other clinicians when dealing with the negative thinking of individuals who are depressed.

* Acknowledge the individual's feelings using empathic statements yet avoid dwelling on his or her depressed outlook: e.g., "I can understand that you feel really bad at the moment, but let's think about what we could do to make this afternoon more enjoyable".
* Ensure clear communication. Strategies for improving communication skills are covered in Chapter 1.
* Try to help the individual adopt a more balanced view of things and focus on more positive aspects of life. Counter the individual's depressed view of things by giving positive messages: e.g., "I'm really pleased that we spent some time together today", "I think you did a really good job at that". Discourage the individual from talking in a negative way and do not agree with or accept unrealistic expectations.
* Individuals who are depressed tend to have difficulty making decisions, even simple ones. It is wise to encourage individuals to avoid (where possible) making difficult or important decisions while depressed. For less important decisions or where decision-making is unavoidable, the clinician may need to help the individual with decision making. Structured problem solving may be useful here (see following page).

Suggested reading

There are a number of books on the market that may be helpful and interesting for individuals, carers, and clinicians. However, individuals who are depressed are unlikely to have a lengthy concentration span so may not derive much benefit from such books until their depression improves. Three recommended books are:

* Greenberger, D. & Padesky, C.A. (1995). Mind over Mood. Guilford Press
* Seligman, M.E.P. (1991). Learned Optimism. Sydney: Random House.
* Tanner, S. & Ball, J. (1991). Beating the Blues. Sydney: Doubleday.

3.1.8 Reducing residual problems

Once the symptoms of depression have been addressed, it will be important to attend to accompanying problems that may be interfering with functioning and well-being. The following strategies will be useful for managing residual problems associated with depressive disorders.

Structured problem solving

Once individuals become depressed they do not think as clearly as before, hence, solving even small problems at this time can be enormously difficult. Furthermore, sometimes the depression and the sense of hopelessness can become so severe and persistent that the individual may come to believe that there is no possible solution to his or her problems. Some individuals when they feel this way resort to the extremely rash and inappropriate solution of suicide.

Researchers have proposed a diathesis-stress model of suicidal behaviour. In this model it is suggested that individuals who are not skilled in flexible thinking and efficient problem solving may, when experiencing high life stress, fail to cope adaptively and thus come to feel hopeless and suicidal. The aim of structured problem solving then is to provide the individual with a systematic and effective means of coping with and solving life problems. This technique is not reserved only for use during episodes of stress and depression, but can be incorporated into daily living so as to prevent later difficulties from escalating into major life crises.

Numerous studies have indicated that structured problem solving can be an effective treatment for depressed and suicidal individuals. Increased ability in problem solving has been shown to reduce depression, hopelessness, and loneliness, and increase perceived self-control. These factors are all implicated in suicide risk, hence, positive changes on these dimensions may reduce the risk of suicide.

The problem solving process includes the following features:

* Defining problems or goals in an everyday manner.
* Encouraging people to seek a wide range of ideas and solutions.
* Defining solutions in terms of current needs and resources.
* Careful consideration of the practical constraints that are involved in successfully applying a solution.

The application and training of the structured problem solving method is discussed in detail in Chapter 1: Core Management Skills.

Improving sleep

Depression is nearly always associated with disturbed sleeping patterns. Generally individuals find that they are sleeping less. They may be waking early in the morning (usually associated with somatic features _ see p. 166) or may have trouble getting to sleep at night. Some atypical presentations of depression are associated with an excess of sleep. Chapter 9 outlines useful guidelines for managing sleeping difficulties. The guidelines are most helpful for those who are oversleeping or having trouble getting to sleep and are less helpful for those who are waking early.

Increasing activity

Another key feature of depression is inactivity. Depression slows people down both mentally and physically. Most things become too much of an effort and the depressed individual tires easily. Individuals find that they are doing less and then feel even worse because they are doing less. They often blame themselves, thus adding to the feelings of depression and demoralisation.

The positive features of physical activity

* Activity makes people feel better and distracts them from their problems and negative thoughts thus giving them a greater sense of control over their lives.
* Activity makes people feel less tired. In the case of depression, inactivity increases feelings of lethargy and leaves the mind free to brood on difficulties and feelings of depression.
* Activity motivates people to do more. The more people do, the more they feel like doing.
* Activity improves ability to think clearly.

Despite these advantages it is still often difficult for people with depression to become more active because of their negative and pessimistic thinking style. They may think, "I won't enjoy it", "I'll only make a mess of it", or "It will be too difficult".

How to increase activity levels

There are a number of important steps associated with helping depressed individuals to manage their inactivity. The involvement of family members or carers will be valuable for helping with activities. The family can assist in the planning process, provide reminders and encouragement, and they may also be involved in the activities themselves.

Rate pleasure and achievement

Find out exactly what activities the individual is doing now and how much pleasure and satisfaction he or she gets from these activities. A good method is to get people to record in a diary or on a sheet exactly what they do hour by hour. Use the activity schedule provided in Section 3.4.4. Ask individuals to rate out of six their sense of pleasure (P) and sense of achievement (A).

Plan activities in advance

Encourage the individual to plan activities each day in advance. This plan will give individuals a sense of control over their lives, will stop them from having to make a lot of minor decisions throughout the day, and will provide a structure so that the day ahead does not seem so overwhelming. Planning the activities involves the following steps:

1. Set aside time to plan the day ahead (e.g., the previous evening or early in the morning).
2. Encourage the individual to start the day with an activity that provides pleasure and achievement. The individual can either:

* Plan more of the activities that have already been rated as high on pleasure or achievement.
* Problem-solve how the time might best be spent by brainstorming different activities or how goals might be achieved.

The list of Pleasant Things to Do in Section 3.4.5 may help individuals think of activities they enjoy. Do not forget exercise as an important activity.

* Suggest that the individual breaks down the day into smaller parts if it seems too difficult to plan a whole day at a time.
* Discuss the importance of obtaining a balance between pleasure and achievement. For example, if the day is filled with duties and chores (which may provide high achievement but little pleasure) there will be little time for relaxation and enjoyment. The individual may feel demoralised at the end of the day. Alternatively, if chores are ignored there may well be a sense that nothing has been achieved and important tasks will pile up and become overwhelming.

Continue to record and rate activities

Ask the individual to continue recording what is actually done during the day and rating the pleasure and achievement levels. These recordings will provide feedback about the individual's progress.

Review activities
Is there any room for improvement? Tasks that have been reasonably satisfying can be built upon. If the individual is still not doing enough with his or her day, or is taking on too much, then the plan may need to be revised.

Hints for planning activities

* If individuals have problems getting started on an activity, encourage them to tell themselves specifically what they need to do (e.g., "Stand up, walk to wardrobe, open the door, reach in with my hands, get out my clothes."). Involve carers by getting them to prompt activities and act as reminders and encouragers.
* Do not let the activity plan be too rigid. Accept disruptions, consider alternatives, and do not try to make up for every activity that has been missed.
* Plan for quality not quantity (e.g., spending half an hour weeding part of the garden is more realistic than planning to weed the whole garden).
* Do not expect miracles. Overcoming depression requires steady work. Even though some activities may help the individual feel somewhat better straight away, these activities do not provide an immediate `cure' for depression.
* When tasks seem overwhelming use goal planning principles (see Chapter 1: Core Management Skills for further details). The basic principles of goal planning are:

1. Specify exactly what needs to be achieved
2. Break the tasks down into smaller steps
3. Use problem solving to plan each step and highlight any difficulties that may occur
4. Focus on what has been achieved after each step has been completed - do not let individuals devalue and discount their achievements
5. Continue with each step until the task is complete.

Exercise

Physical exercise is beneficial for reducing depression. Some of the benefits of exercise are listed below:

* Exercise may cause biochemical changes which counteract the chemical imbalance associated with depression. Some joggers report feelings of euphoria after a solid workout.
* Exercise is a distraction from depressive thoughts. Temporary preoccupation with exercise (e.g., breathing, mastering relevant skills, dodging obstacles along a jogging route, tired or aching muscles) can take the focus away from depressive thinking.
* Exercise can increase self-efficacy. The individual may master new skills or notice an improvement in health and body shape as a result of the exercise. Also, exercise can provide a sense of control by allowing the individual to engage in a self-disciplined activity that benefits well-being.

Encouraging eating behaviours

One of the key symptoms of depression is weight loss. Although some people may eat more (especially sweet foods) when they are feeling down, people who are more severely depressed seem to eat very little at all. Common reasons for eating so little include: lack of appetite; loss of interest and enjoyment in food; and lack of energy required to get up and prepare a meal.

For severely depressed individuals, it would not matter how attractively food is prepared - they have no appetite. However, when individuals are not severely depressed, family members may be able to utilise the strategies outlined in Section 3.4.6.

If weight loss continues to be a problem, it may be helpful for individuals and carers to deal with this issue using a problem-solving framework (see Section 3.1.8). Write down the problem to be solved (e.g., getting Bob to eat three small meals a day) then brainstorm about different ways of achieving this goal. Examine all possible solutions and motivators then choose the best options. Write down specific details about how this goal is to be achieved (who does what) then put the plan into action.

Relaxation training

Many individuals who are depressed may also experience significant problems with anxiety. It is often useful to teach individuals about non-drug methods of anxiety reduction. One method that can be very effective if used appropriately and regularly is progressive muscle relaxation. Other forms of relaxation such as tai chi or meditation can also be useful. Detailed information about relaxation training and other anxiety reduction techniques is covered in Chapter 4. Clinicians are referred to that chapter for instructions and handouts.

Assertiveness and clear communication

It is important that individuals who are depressed increase the number of enjoyable activities in their lives. For most people enjoyable activities often involve interacting with other people. Individuals who are depressed often feel uncomfortable in social situations and are particularly sensitive to rejection or criticism from others. They may also have problems expressing their feelings honestly to other people. Bottling up angry feelings makes it more difficult to deal with stresses or conflicts. Clear and assertive communication will be especially important in close interpersonal relationships.

Learning how to interact with others by communicating needs and feelings more effectively will give people more control over their lives. This sense of control is particularly important for individuals who are recovering from depression.

Assertiveness training

Assertiveness involves being able to communicate effectively with people and being able to express needs and feelings in a direct and non-confrontational manner. Assertiveness training is aimed at helping people learn to stand up for themselves in a polite and appropriate way. People who are not assertive may find that their needs are not being met or that they are continually giving in to other people's demands. They will often choose to `keep the peace' rather than risk starting an argument. Furthermore, people who are not assertive often feel compelled to do things they would rather not do because they do not know how to refuse.

People who are depressed are particularly likely to have trouble asserting themselves because they feel that they are worthless and undeserving. Such feelings make assertiveness difficult. Depressed people are also likely to feel helpless, as if they have no control over what happens to them. Assertiveness training helps people gain control and reduce feelings of helplessness.

Not everyone who is depressed will need such training because many depressed people are normally quite assertive when they are well. However, other depressed people may have long-standing difficulties with assertiveness and are more likely to benefit from such training.

Further information about conducting assertiveness training groups is provided in Chapter 1: Core Management Skills.

Role of clear communication

Being assertive involves communicating thoughts in a clear and polite manner. Sometimes it is necessary to ask others to change their behaviour, or to make a request, or ask for a favour. If requests are not communicated clearly, the other person can often take offence. Therefore, to become assertive and get what is wanted without offending or alienating others, it is important to know how to communicate effectively. Information about communication skills training is provided in Chapter 1: Core Management Skills.

3.1.9 Preventing relapse or recurrence of depression

Recurrence is a considerable risk after recovery from a major depressive episode. It has been estimated that more than 50% of individuals with recurrent depressive episodes will have another episode of depression within two years of recovery. Other individuals may relapse; that is, they experience partial remission from their depressive episode but then experience further deterioration.

It has been demonstrated that the individuals who may have the greatest risk of relapse are those who:

* Have significant levels of depression at the end of treatment (e.g., as measured on self-rating scales such as the DASS of PHQ-9).
* Continue to have a negative thinking style after treatment.
* Have been depressed for long periods of time (dysthymia) or have had prior recurrent episodes - individuals who have had three episodes of major depression have a 90% chance of having another episode.
* Continue to live in a stressful home environment or who remain dissatisfied with major areas of their life.
* Have co-existing medical problems.

Relapse prevention strategies

1. If individuals appear to be at higher risk of relapse they will need to be monitored more carefully and regularly (e.g., monthly) over the two years following treatment termination. It will also be important to encourage long-term adherence to the treatment programme, whether the treatment involves medication or psychological strategies. Guidelines for encouraging adherence are covered in Chapter 1: Core Management Skills.

2. Involvement of partners and carers will be very important for assisting with many of the relapse prevention strategies. Relatives can encourage depressed individuals to use the skills that are outlined in this section. They can also help to monitor the individual's mood. In addition, they can have a considerable influence on the quality of the depressed individual's relationships and social supports and can therefore influence speedy recovery and help to prevent recurrence.

3. Long-term maintenance antidepressant medication is usually recommended for individuals who have experienced three or more episodes of major depressive disorder. Maintenance medication is also recommended for individuals who have:

* Experienced two episodes of major depressive disorder and who have a clear family history of bipolar or depressive disorder.
* Had an early onset of the first depressive episode (before 20 years of age).
* Had previous episodes that were sudden, severe, or life-threatening.
* Had recurrent episodes that occurred within one year of discontinuation of effective antidepressant medication.

4. Since life events, a stressful home environment, and medical problems all appear to make an individual more vulnerable to further episodes of depression, strategies that deal specifically with these issues could be implemented before treatment is terminated. For example, further sessions might target:

* Problem solving strategies for dealing with current life problems (see Section 3.1.8).
* Training in communication and assertiveness skills if interpersonal problems are apparent (see Section 3.1.8).
* Medical problems to ensure that they are adequately managed and that the individual is in regular contact with his or her local medical practitioner.
* The planning of coping skills for any predictable life events (see the following discussion about high risk situations).

High risk situations

Using information relating to relapse prevention for addictive behaviours, researchers have developed a relapse prevention strategy that aims to teach individuals how to anticipate and cope with problems that might lead to relapse.

1. The first step is to identify high risk situations. These situations may be:

* Loss events typically associated with depression such as personal losses (relationship break-ups, moving house, illness), or financial and status losses (loss of a job, failed business ventures).
* Events that are particularly significant to the individual. The following issues will need to be examined:
* What events have been particularly devastating or associated with the onset of depression in the past?
* What events have been significant over the course of the current episode?

2. As it is often impossible to avoid adverse life events, the second step is to prepare for high risk situations.

* Individuals need to be aware of their particular high risks situations so that these situations can be easily recognised when they occur.
* Help the individual plan exactly how he or she could respond most effectively in these situations. Ask the individual to keep a written plan for future reference. One aim of planning is to encourage individuals to realise that they can cope with these situations if they do indeed occur (even if these situations are unlikely). For example, one high risk situation may be losing your job. The planning steps could involve the following.

Planning step in relapse prevention

Early warning signs of relapse

As with other mental disorders it is likely that some individuals will be able to identify changes in their thoughts, feelings, or behaviours which may signify that they are becoming depressed again. By being aware of early warning signs and acting immediately on these signs it may be possible for the individual to decrease the potential severity and duration of the episode.

Early warning signs will be slightly different for each individual. However, common signs are:

* Changes in sleeping patterns (particularly early morning awakening or oversleeping)
* Decreased concentration
* Withdrawal from usual social activities
* Lack of energy
* Poor memory
* Irritability
* Loss of interest in activities that are usually pleasurable
* Lowering of mood

Identification of early warning signs

The aim is to identify early warning signs that are:

* Individualised
* Specific and if possible defined in behavioural terms (e.g., `Waking up at about 5 a.m. for 3 mornings in a row' or `Have not enjoyed my food for the last 5 days').
* Described in terms which are understandable to the individual and his or her carers (e.g., `Few facial expressions and decreased amounts of speech or participation in everyday activities' is better than `psychomotor retardation').

In some cases, particularly if there have been numerous episodes of illness, early warning signs may be identified retrospectively. In other words, if an individual experiences a recurrence or relapse, the individual and his or her carers can look back at the individual's behaviour prior to the relapse in an attempt to identify any characteristic early warning signs that may have been present.

The following individuals may be helpful for identifying specific early warning signs:

* The individuals who has the disorder
* Family members, carers, or other household members
* Mental health professionals or the family doctor if they are in regular contact with the individual
* Any other person who is in regular contact with the individual

Questions for identifying early warning signs

For example, you might ask individuals and their carers:

* Can you think back to when you (your relative) first began having difficulties with ... [symptom/s of illness].
* What exactly was going on at the time?
* What thoughts, feelings, or behaviours did you notice?
* Did you notice anything unusual or different before that time?
* How long did you (your relative) have these changes in behaviour before becoming unwell?
* What was the first thing you noticed that was different about your (your relative's) thoughts, feelings or behaviours?
* After first noticing ... [the symptoms], how long was it before the illness started?

If the individual or family cannot identify any changes, you may want to prompt for common signs. For example:

* Did you find that you were losing interest in activities that you used to enjoy?
* Did you start to wake up earlier than usual and find that you couldn't get back to sleep?

Specific early warning signs could then be documented clearly for future reference. In addition, a clearly specified plan of action will help the individual or family understand what to do if the early warning signs occur again.

The early warning signs form developed by Ian Falloon is a useful way of documenting early warning signs. A blank form and a worked example are contained in Chapter 5: Schizophrenic Disorders. The immediate action plan is best developed in consultation with the individual, his or her family, any health professionals who might be involved (e.g., the crisis team), or the individual's doctor if the plan involves any changes to medication.

Involvement of carers

The involvement of partners, families, and other carers is especially important for monitoring the characteristic pattern of signs and symptoms that may indicate an impending episode. Individuals experiencing a recurrence of illness will very quickly lose their usual judgement and insight and fail to view changes in mood and behaviour as being a problem.

Carers will need to be alert to these changes and be prepared to take appropriate action. For example, it will be necessary to contact the appropriate health professionals for early intervention. An explicit plan of action or contract (e.g., who to contact and when) should be negotiated with the individual when he or she is symptom free between episodes. This plan of action needs to be documented in a formal written agreement. A trusting and co-operative relationship between individuals, carers, and health professionals will facilitate effective management of the illness.

Also important is the provision of continuing education about the advantages of monitoring early warning signs, predicting relapse or recurrence, and the early implementation of preventive strategies. This education is particularly important if the individual chooses not to accept or continue long-term prophylactic medications but instead relies on early intervention following the detection of early warning signs.

Early intervention strategies

Following the detection of early warning signs, strategies that aim to minimise the risks associated with a recurrent episode need to be employed. These strategies include:

* Medication review
Psychiatric consultation and assessment will be required.

* Increase contact and support for the individual and his or her family

The presence of signs which, in addition to being disruptive in themselves are possibly indicative of an impending relapse, will place increased strain on individuals and particularly on their families. Regular contact and support is important for the purposes of: lessening anxiety; sharing the burden of responsibility; and ensuring quick access to services (specialist consultation, crisis or extended hours teams, inpatient care) should these services be required.

Plan for setbacks

In addition to planning for high risk situations and early warning signs it will also be important to plan what individuals can do if they find themselves depressed again (since we know this is a likely occurrence for many individuals). Ask individuals to write down exactly what they will do if another period of depression occurs. An example is given below:

What can I do when I experience a setback?

1. I can choose how I wish to behave. I can become upset and angry about what has happened and tell myself than things are hopeless, which will probably make me feel even more depressed. Or, I can tell myself that setbacks are to be expected and that I have been doing well up to this point, which will probably make me feel better and make the setback seem less severe.
2. I can think back to the last time I was depressed and try to remember what helped me feel better at that time. I can also plan how to solve my current problems. (The plan may include strategies such as structured problem solving, ensuring that there are enough pleasant activities in my daily routine, exercise, and managing sleep and eating).
3. I can contact my clinician or doctor and briefly tell him or her what has happened and how I am coping. I can make an appointment to see my clinician.

3.1.10 Depression and childbirth

Depression after childbirth can take three main forms: postnatal blues (baby blues), postnatal depression, or puerperal psychosis. Postnatal blues is experienced within a few days of childbirth while the women is still (usually) in hospital and generally lasts only hours to days. Therefore, this transient and mild mood disturbance is not discussed in this chapter.

Postnatal depression

Postnatal (or postpartum) depression is most appropriately described as depression that has its onset within 3 months, and possibly up to 6 months following childbirth. Depression that occurs after this time is best considered to be major depression and not postnatal depression.

The symptoms of postnatal depression are the same as those experienced in a major depressive episode. Symptoms include:

* Anxious and/or depressed mood
* Exhaustion and loss of energy
* Sleep and appetite disturbance
* Memory and concentration difficulties
* Feelings of guilt/shame/anger/incompetence/hopelessness
* Suicidal thoughts, plans, or actions
* Loss of libido
* Obsessional thoughts or activities
* Fear of going outside the home
* Exaggerated fears concerning the self, the baby, the partner

Postnatal depression is much less common than postnatal blues, affecting (respectively) approximately 10% versus 70% of new mothers. The depression usually lasts anywhere from a few weeks to a year or more. If untreated, postnatal depression may become a chronic disorder. With appropriate monitoring and intervention, it is possible to reduce the prevalence of such depression and perhaps even to prevent recurrence in the future. Postnatal depression is very common in women with untreated bipolar disorder.

Aetiological factors

There does not seem to be a sole cause of postnatal depression. Rather, multiple factors are likely to be involved. Some possible factors include:

* An inherited vulnerability to develop an affective disorder
* A history of affective illness
* Personality style (e.g., trait-anxiety, over-sensitivity)
* Dysfunctional relationships
* Social stresses (e.g., lack of a partner or family support, financial difficulties)
* Physiological stresses (e.g., hormonal and biochemical changes, fatigue, physical complications associated with pregnancy or birth, drugs)

Predictors of postnatal depression

The following indicators may suggest an increased likelihood of postnatal depression.

Antenatal (before birth) indicators

* Severe pre-menstrual syndrome
* Previous pregnancy or birth-related crises (e.g., miscarriages, terminations, stillbirths, neonatal death, premature birth)
* Relationship difficulties with partner, mother, or father
* Poor social supports
* A vulnerable personality style (e.g., trait anxiety, over-sensitivity)
* Recent bereavement
* Marked depression in pregnancy
* A family or personal history of psychiatric illness
* Stressful life events (e.g., illness in self or partner, moving house, changing job)
* Present pregnancy is unwanted; termination was considered; or obstetric complications were present
* Previous antenatal or postnatal anxiety or depression, or escalating anxiety during pregnancy
* The indicators marked by asterisk may be particularly important indicators of high risk postnatal depression.

Postnatal indicators related to the birth process and management may include

* Delivery complications such as birth by caesarean section *
* Handicapped or ill baby
* Baby not of desired sex
* The birth process did not fulfil expectations (e.g., unwanted intervention) *

Postnatal indicators related to the mother's or baby's behaviour and mood include

* Continuing postnatal blues
* Not wanting to hold the baby
* Detached or negative feelings about the baby
* Lack of direct eye contact
* Inability to sleep or excessive sleep
* Feeding difficulties
* Anger about life circumstances
* Withdrawn behaviour
* A baby with a difficult temperament
* Presence of colic or reflux in the baby

It will be important for clinicians to determine the presence of such indicators among women who have recently given birth. It is important for health workers to focus on the mother's psychological health, not simply on her physical health and the physical health of her child.

Assessment

The Edinburgh Postnatal Depression Scale is a widely used scale for the detection of depression following childbirth. This scale (reproduced in Section 3.4.7) is filled out by the individual, takes about five minutes, and is easy to score. Response categories are scored 0, 1, 2 and 3 according to increased severity of the symptom. Items 3, 5, 6, 7, 8, 9 and 10 are reverse scored (i.e., 3, 2, 1 and 0). For example, for question 2, `As much as I ever did' is scored as 0 while `Hardly at all' is scored as 3. In question 5, `Yes, quite a lot' is scored as 3 while `No, not at all' is scored as 0. The total score is calculated by adding together the scores for each of the ten items.

Scores of more than 12 or 13 indicate that the mother is likely to be suffering from a depressive disturbance, and scores as low as 9 or 10 may also be associated with significant depression. These women need to be assessed carefully for the presence of a major depressive episode. Low scores do not necessarily indicate an absence of depression and clinical judgement needs to be used, especially if the clinician has good reason to believe that the woman may be depressed.

Management

The management of postnatal depression can be broken down into the following steps:

Identify the presence of postnatal depression
Look for postnatal depression if:

* The woman is a frequent attender who uses her baby as a `ticket of entry', or the baby has colic or reflux.
* Risk factors are present, such as a known dysfunctional relationship, a previous history of depression, or other indicators listed previously.
* There is evidence of poor coping skills.
* The partner is concerned.

Screening will be important and includes the Edinburgh Postnatal Depression Scale and further information about the woman's history.

Provide an explanation and education about the disorder
Let the woman know what is happening to her. It is often that case that women experience a certain amount of relief just from having their disorder recognised and labelled. Women often worry that they are going crazy or that the depression signifies personal failure or that they are an unfit and incompetent mother. It may be helpful to say, "You are suffering from postnatal depression."

Explain what postnatal depression is. It is helpful for women to be informed that postnatal depression is not an uncommon disorder following childbirth and that this depression is not the result of personal shortcomings. It may be helpful to say, "You are not alone", or "You are not a bad/defective mother."

Explore contributing factors

Identify any factors that are contributing to the depression. Possible areas to explore include:

* A history of depression
* The woman's obstetric history
* The quality and state of the woman's relationship
* The availability of social support
* Personality style
* Difficulties with the baby
* Life stresses

Give permission to talk

Give the woman permission to talk openly about:

* Her relationship with her partner.
* Any disappointments or stresses she may be experiencing with her new role.
* Ambivalent feelings towards the baby (e.g., frustration, resentment). It may be helpful to point out that such feelings are not uncommon.

Organise practical help

The clinician can assist by:

* Organising help with childcare.
* Placing the woman in touch with support organisations, such as Nursing Mothers Association of Australia.
* Helping the woman to recruit support from family and friends.
* Referring the woman to a mothercraft centre.

Provide or refer for specific treatments

Useful specific treatments include:

* Marital counselling.
* Individual counselling.
* Psychotherapy, such as cognitive behavioural or interpersonal therapy.
* Antidepressant medication.

Marital counselling

* Educate the partner about postnatal depression and the demands of being a mother.
* Point out to the partner that the woman is in need of practical and emotional support.
* Deal with specific relationship problems.

Counselling

Basic counselling skills that will help the woman express and think about her problems are outlined below. In addition, readers are referred to Section 1.1.5: Building a Therapeutic Relationship.

* Be an active listener (i.e., look at the person, show attentive body language, use appropriate vocal tone and speech rate, and allow the person an opportunity to talk without interruption).
* Encourage the woman to make decisions that are based on her own judgement rather than giving advice. Structured problem solving will be useful here (see Section 3.1.8).
* Provide non-verbal encouragement, such as nodding.
* Reflect back to the woman your understanding of what she has said.
* Provide a confiding relationship.
* Be empathic and non-judgmental.

Medication

Indications for antidepressant medication include:

* Severe depression.
* Marked vegetative features.
* Psychomotor disturbance.
* Concomitant panic disorder.
* The individual is not psychologically minded and therefore may not benefit adequately from counselling alone.
* The individual has not responded to non-pharmacological treatments.

SSRIs are the first line drugs for the treatment of postnatal depression. Women can continue breastfeeding but only sertraline among the SSRIs is not found in significant amounts in breast milk. Paroxetine and fluoxetine are found in breast milk in substantial levels, but studies reveal no adverse outcomes. However, side effects may be a problem.

Psychotherapy

Cognitive behaviour therapy (CBT) or Interpersonal therapy (IPT) are appropriate treatments, but will require referral to a trained professional. CBT aims to replace dysfunctional thoughts such as "I'm a bad mother" or "It's all my fault" with realistic thoughts (see Section 3.1.7). Another CBT strategy that may be useful is activity planning (see Section 3.1.8).

When to refer
Clinicians are advised to refer:

* If the woman is `difficult' or has personality problems
* If there is a history of depression
* If the woman does not respond to treatment
* When unsure

Prevention and early intervention

The prevention of postnatal depression has received inadequate attention to date. However, a number of strategies may be useful for minimising the risk of developing this disorder. Such strategies include:

Prenatal education

This education would include information about postnatal depression and the difficulties that may be experienced during the transition to parenthood. Some clinicians are concerned that informing women about the risk of postnatal depression may cause unnecessary worry. However, it is often the case that women would prefer to be informed. Prenatal education about postnatal illness can enhance the couple's ability to recognise postnatal illness and to seek appropriate assistance if required, thereby preventing or minimising serious disability and distress.

Enhancing coping and stress management techniques

Techniques such as relaxation training, cognitive restructuring, and assertiveness training may be useful for preventing the escalation of stress and coping difficulties. Particularly, women would be encouraged to use stress management and coping strategies that have been effective for them in the past. Additionally, it is also recommended that women take steps to enhance their social networks prior to birth if the present social network is inadequate. Also, in this era of cost constraints and rapid discharge from hospital following delivery, advise mothers to arrange for extra support at home for at least two weeks, either friends, family, or professional help.

Puerperal psychosis

The other important postpartum mood disorder is puerperal psychosis. This disorder affects approximately 0.1% of women who have recently given birth and develops within 3 weeks following delivery. The cause of disorder may be related in part to rapidly changing hormone levels following childbirth. Most puerperal psychoses are either depression with psychotic features, manic or mixed states.

This disorder is serious and requires prompt psychiatric treatment. Hospital admission may be required and will preferably be provided at an institution that will care for both the mother and baby together.

Puerperal psychosis has a good prognosis with proper treatment. There is usually a return to a normal level of functioning within a few months. However, one in four women who have experienced puerperal psychosis are likely to develop further episodes of illness with subsequent pregnancies.

Edited by Gavin Andrews MD, UNSW, 2007
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