Depression

Depression
Major Depressive Disorder
Pleasant Events Scheduling
Structured Problem Solving
Medication
Tricyclic antidepressants
Serotonin Reuptake Inhibitors
Monoamine Oxidase Inhibitors
Other Medications
St John's Wort (Hypericum)
Electroconvulsive Therapy (ECT)
How do I choose a treatment?

See also www.climateclinic.tv for a web based treatment package we are currently trialling. They contain elements of the cognitive behaviour therapy in an illustrated story line to show you just what to do to recover. Pictures are much better than words.

What is depression?
Depression is one of the common human emotional states. It is common to experience feelings of sadness and tiredness in response to life events, such as losses or disappointments. In most cases, as you come to terms with changes in life, the sad feelings resolve. In situations such as bereavement, these feelings may persist for months and return at significant times such as birthdays and anniversaries related to the lost loved one. Sometimes people continue to feel sad, even if there seems to be no apparent reason. Some people may become depressed without any clear precipitating event. This is the type of depression which may need more assertive management. Depression may be seen along a continuum: from transient feelings of sadness, to a severe persistent mood change with physical symptoms. Between 20-30% of people will experience a major depressive episode at some stage in their lives.

What is Major Depressive Disorder?
Major depression is a syndrome characterized by persistent low mood, loss of enjoyment and biological symptoms.

Its features include:

• Low mood or feelings of sadness or irritability, most of the time. The mood may be worse at certain times of day, typically in the morning.
  
  
• Loss of interest in one's surroundings, loss of enjoyment in activities, decreased sex drive.
  
  
• Sleep disturbance: difficulty getting off to sleep, or waking in the early hours of the morning and finding yourself unable to get back to sleep.
  
  
• Negative thoughts regarding yourself, surroundings and future. Often a person may become guilty over real or perceived misdeeds. In severe depressions of a 'psychotic' type, the person may develop untrue beliefs regarding themselves and others, and may experience hallucinations.
  
  
• Appetite disturbance: increase or decreased, which may be accompanied by weight changes.
  
  
• Fatigue and loss of energy
  
  
• Physical symptoms such as vague abdominal discomfort and headaches, often associated with anxiety.
  
  
• Problems with concentration and memory difficulties.
  
  
• Feelings of agitation or feeling 'slowed down'.
  
  
• Thoughts of death or suicide: such thoughts indicate the need for professional help.

What causes depression?
Descriptions of depressive illness have been documented as far back as in ancient Greece, in the writings of Hippocrates.

In the 20th century, researchers have attempted to categorize different types of depression. There is still debate regarding types and causes.

Theories include:

• Primary vs secondary: depression occuring independently, or as a manifestation of another psychiatric illness (eg bipolar disorder) or medical problems (eg thyroid illness, infections, anaemia, neurological illness eg. after a stroke, as a side effect of medications for other medical conditions, or secondary to substance use (alcohol, cannabis, cocaine, amphetamines etc).
  
  
• Reactive vs endogenous: depression as a direct result of life events, or arising for no apparent reason.

• Biological theories: researchers have found changes in the regulation of 'biogenic amines': brain chemicals (neurotransmitters), such as serotonin and noradrenaline. Other hormonal systems within the body, and the immune system may also be affected

• Genetic influences: first degree relatives of a person with major depression are at a 2-3 time higher risk of having an episode in their lifetime.

• Psychological and social influences: anxious and tense people may be at higher risk. Adverse life events may precede an episode of depression: childhood adversity, major losses in adulthood and low social support levels (friends, community) may increase risk.

What treatments work?
In general, the severity of depression will dictate the most appropriate treatment. The presence of biological symptoms may mean that biological treatment (eg medication) is indicated.

Treatments for depression which have been proven to be of benefit in scientific trials include:

• cognitive behavioural therapy
  
  
• interpersonal therapy
  
  
• antidepressant medication
  
  
• electroconvulsive therapy

Cognitive behavioural therapy:
Milder depressions have been shown to respond to some simple behavioural techniques.

1)Exercise and Pleasant events scheduling:
Depressed people often find themselves losing enjoyment of their surroundings and activities. The logical response to this is to stop doing things and become socially withdrawn.

The effect of this is twofold: the person loses contact with the anti-depressant effects of the environment, and robs themselves of the possibility of enjoying something and feeling pleasure. Likewise, an isolated person is left alone to think about their unhappiness, thus reinforcing this view of their situation.there are two strategies, exercise and activity

Physical exercise relieves depression: 20 minutes a day of brisk walking will do, best if it is done in the morning and in the sunlight.

Pleasant events scheduling involves activating oneself: scheduling in on a daily basis an activity which you had previously enjoyed, or will give you a sense of achievement.

Some researchers have found that regular exercise results in the resolution of mild depression.

2) Structured problem solving :
If you feel your depression is related to problems in your life, this technique offers a framework for attempting to resolve these problems.

The Six Step Method Of Structured Problem Solving

Step 1: Identifying problems
Gaining a clear definition of the problem or goal is a vital step in problem solving. Defining problems or goals helps to focus thinking on the issue at hand and minimises the possibility of getting side-tracked onto other issues. Also defining problems and goals makes it easier to know when the goal has been achieved or the problem solved.

At this stage of problem solving there are some `rules' that will help to suitably define goals or problems. Encourage individuals to:

• Only consider one problem at a time. If other problems arise in the course of the session they should be set aside for a problem solving session in the future.
  
  
• Avoid getting side-tracked into attempting to solve the problem at this stage.
  
  
• Apply the principles of goal planning (see Section 1.1.8).

Step 2: Generating solutions through brainstorming
Brainstorming is a method by which individuals come up with as many alternative solutions as possible. Rather than try to think of the best or ideal solution, the individual can list any ideas that come to mind, including those which may not be useful or may even be absurd. Encourage individuals to use their imagination! Even though a solution may at first seem ridiculous, the idea may help to generate better solutions than those that are more obvious. At this stage of problem solving there is no discussion of the solutions, they are just listed.

Step 3: Evaluating the solutions
This step involves a brief discussion of the advantages and disadvantages of each solution. There is no need for the individual to write these points down but just quickly run through the list of solutions, noting the strengths and weaknesses of each. No solution will be ideal since every good idea will have some faults, such as requiring time or money, or skills that individuals do not currently possess. However, most bad ideas will also have some advantages as well. For example, they may be easy to apply but may not really solve the problem in the long run.

Step 4: Choosing the optimal solution
In this step the aim is to choose the solution or combination of solutions which will solve the problem or achieve the goal. It is often helpful for the individual to choose a solution that can be readily applied and which is not too difficult to implement, even though this solution may not be the ideal solution. At least individuals can get started right away. Although the problem may not be solved immediately, the `solution' might have made a difference, and what is learned from this attempt might be useful the second time around. This approach is preferable to choosing a solution which is doomed to failure because someone has been overly ambitious.

Step 5: Planning
A detailed plan of action will increase the likelihood that the problem will be solved. Even if the agreed solution is excellent, the solution will not be of any use if it is not put into practice. The most common reason for failure is a lack of planning. Be sure that individuals spend some time on this planning stage. Cues, reminders or rewards may need to be incorporated into the plan

The following checklist (adapted from a checklist developed by Ian Falloon) applies to any problem and will be helpful in pinpointing any pitfalls or obstacles in the solution plan.

• Does the individual have the necessary resources (e.g., time, skills, equipment, money) or are you able to arrange the necessary resources, or personal or expert help? Expert help may include other members of your team (social work, occupational therapy, psychiatric or clinical psychology consultation).
  
  
• Does the individual have the agreement or co-operation of other people who might be involved in the plan?
  
  
• Does everyone involved in the problem solving exercise know exactly what they need to do and when they need to do it? Setting specified times or deadlines will minimise the risk of procrastination.
  
  
• Have all the steps been examined for possible difficulties?
  
  
• Has the individual planned any strategies for coping with likely difficulties?
  
  
• Has the individual planned any strategies for coping with any consequences that may arise? For example, if the individual applies for a job, what happens if he or she does not succeed? Or if they get the new job and have not considered what the demands of that job may entail.
  
  
• Have difficult parts of the plan been rehearsed? (e.g., a telephone call, conversation, or interview).
  
  
• How will the steps of the plan be monitored? If the plan involves a number of people it will be useful to nominate a co-ordinator to monitor progress and to prompt and remind people when they need to do the things they agreed upon. Include this monitoring as part of the plan so that everyone agrees and is prepared to be reminded.
  
  
• Has a time and place been set for a review of the overall progress of the plan?

Step 6: Review
Problem solving is a continuing process since problems are often not resolved nor are goals always attained after the first attempt. Not all possible hitches are considered at the planning stage and so ongoing reviews are necessary to cope with unexpected difficulties. Steps may need to be changed or new ones added. It will also be important to praise all efforts that have been made. If you reward everyone involved for the work that has been done it is more likely that the structured process will be followed and that problems will be solved in the future.

When things do not go as planned:

• What went right?
  
  
• What went wrong?
  
  
• What alternative strategies could be used?
  
  
• Encourage the individual to acknowledge feelings of disappointment, but do not allow disappointment to turn into a catastrophe.
  
  
• Difficulties are usually due to a poorly planned strategy rather than personal inadequacy. Everyone does the best they can do.
  
  
• Label any attempt as partial success rather than failure.
  
  
• Consider partial success as practice and a useful learning experience.
  
  
• Encourage the individual to try again as soon as possible.

3) Cognitive therapy:
Depressed people typically have a negative view of themselves, the world and the future. Cognitive therapy aims at identifying unhelpful patterns of thinking, and replacing these habits with more helpful, realistic thoughts.

Medications for depression
In scientific trials, approximately 60% of people with depression have been shown to respond to medication. Response rates appear to be the same between groups of drugs. Some individuals may respond to one drug but not another.Choice of medication is related to side effects, other medical conditions, cost and previous response.

Serotonin reuptake inhibitors: include

• sertraline
• fluoxetine
• citalopran
  

It is suggested that after a single episode of major depression, medication should be continued for twelve months - as this is the period when a recurrence is most likely. If you have had more than one episode, it is suggested that medication be continued for three years.

St John's Wort (hypericum):
St John's wort is a plant extract, which some research has suggested is of benefit for depression. If you are taking this preparation, you should inform your treating practitioner, as it may interact with medications used for depression.

Electroconvulsive Therapy (ECT):
ECT remains a controversial treatment. In some parts of the world, its use is prohibited. The practice of ECT involves using an electrical charge to activate the portions of the brain involved in mood and emotions. In modern ECT, the treatment is given under a general anaesthetic, so the person receiving treatment does not feel it. A muscle relaxing agent is given to avoid jerking movements during treatment. The scientific evidence for ECT is as follows: ECT is a safe treatment. In the elderly age group, it may be safer than medications. ECT is highly effective for severe depression: response rates are around 80%, vs 60% for medications. There is no good evidence that ECT causes brain damage. Memory problems are common during a course of treatment, and may persist for some months afterward. These are not thought to be permanent problems.

How do I choose a treatment?
Choice of treatment depends on many factors: including the severity of depression, availability of treatments, and your own feelings about the use of medication or other therapies.
We suggest the following:

Mild depression: may resolve with exercise, pleasant events scheduling and structured problem solving.

Moderate depression:medication, or psychotherapy (cognitive behavioural or interpersonal), or both

Severe depression: medication initially, which may later be supplemented by psychotherapy to reduce the likelihood of relapse

Severe depression complicated by poor food or fluid intake, or psychotic symptoms: medication or ECT

If you are currently suicidal:
We encourage you to see a health professional as soon as possible.

What happens if depression is left untreated?
An untreated episode of major depression usually lasts six to twelve months. There is a significant risk of suicide (10-15%), and relapses are common (up to 50 percent in 2 years after the first episode).

What are my chances of getting better?
Of people treated with medication and/or psychotherapy, 60-70% of people can expect a full recovery within three to four months.

Edited by Gavin Andrews MD, UNSW,2007
©2007 CRUfAD