Addiction Treatment Blog

At Eternity's Gate by Vincent Van Gogh

What Is Depression?

‘The black cloud’, ‘I just feel so sad’, ‘It’s like wading through mud’, ‘A feeling of utter hopelessness’, ‘Everything seems pointless’, ‘It’s all such a struggle’, ‘I’m useless’.

Everyone feels a bit low or ‘down’ once in a while but depression is quite different, often making it a struggle to get on with even the simplest tasks in your life. It is a recognizable illness marked by a prolonged period of low mood, sadness and feelings of apathy that has a significant impact on day-to-day life and its enjoyment and that lasts for more than a month. Sadly, untreated depression can be a killer disease with the major proportion of the 4000 suicides a year in England being attributed to depressive illness.

What It Isn’t?

Depression is often called the ‘common cold’ of psychiatry. ANYONE can experience depression – even your GP! However, it is a condition that can be difficult for others to understand. People who have not experienced depression may tend to dole out platitudes – such as ‘Pull yourself together’ and so on. Depression is NOT a passing feeling of low mood or sadness. NEITHER is it a sign of ‘weakness’ or lack of ‘machismo’. It is not a sign of ‘madness’, whatever you think ‘madness’ is. Depression is sometimes referred to as ‘clinical’ depression – this just means depression needing treatment. The good news is that, in the vast majority of cases, depression is highly treatable.

How Depressed People Think, Feel and Behave

Depressed people typically have a negative view of themselves, people around them, their environment and the future. They have often stopped enjoying things that they used to like. A depressed person might ask you, ‘Why does everything bad happen to me?’, they may tell you that they’re a ‘failure’, that everything is meaningless’ or that everyone else is awful or that there is no hope for the future and everything looks bleak. Depression colours your thoughts – painting them shades of grey / blue right through to black. These negative thoughts keep the depression going and part of many treatments and/or self-help is likely to look at ways of recognizing and challenging patterns of negative thinking. Depression influences the way you behave – if everything is pointless and hopeless and everyone is awful, what’s the point in doing anything, seeing anyone? Depressed people often tend to do very little – although some times they will overdo things in order to avoid thinking. Depression ‘takes’ everyone in different ways.

The Symptoms of Depression

Typically the symptoms of depression, as identified by medical professionals and mental health team workers include: changes in appetite; suicidal thinking; hopelessness; lack of motivation; sleep difficulties in making decisions; memory difficulties; feelings of guilt, worthlessness and emptiness; difficulties concentrating; unexplained physical symptoms; a change in alcohol intake (ideally don’t drink alcohol if you are depressed – it can seem like a good idea at the time but remember it’s actually a depressant! That’s why we lose our inhibitions when we’re a bit ‘tipsy’!); feeling anxious; taking street drugs to excess.

Types of Depression

Depression is thought of as having levels of severity and causes. Some people refer to ‘reactive’ or ‘exogenous’ depression which is usually directly related to an external event. ‘Endogenous’ depression is a term for a depressive episode for which, initially at least, no clear precipitating factors can be identified. Depression is often classified by professionals as being mild, moderate or severe with one of the major defining factors being the impact of the illness on a person’s life and relationships. Some people experience dysthymia, a mild form of depression, usually lasting two years or more, marked by a pervasive feeling of low mood and general unhappiness. Many people will experience just one or two episodes of depression over a lifetime. Others may experience more than three episodes of depression over a lifetime – which may be considered as ‘recurrent’ or ‘chronic’ depression. Depression is also part of what is called manic depression which is marked by significant mood swings – cycling through periods of mania and depression. Depression with periods of mania is often called bipolar depression. Occasionally people can experience an episode of psychosis with depression, particularly with severe depression.

Confusion!

People are often confused about depression in that it can be associated with other psychological disorders – you can, unfortunately, for example, be depressed AND anxious, have alcohol problems AND be depressed and so on. Sometimes one difficulty keeps another one going.

Triggers for Depression

Triggers for an episode of depression might include: the loss of a job; extended grief following a bereavement; stress; the birth of a child (post-natal depression); work stress; lack of social support (for example, following a house move); relationship difficulties; physical illness; and the weather (Seasonal Affective Disorder (SAD)). Sometimes the trigger is not clear and the depression just seems to ‘come out of the blue’. There are a number of factors that may make certain people vulnerable to depression.

What Makes People Vulnerable To Depression?

At present, it is considered that there is a genetic as well as a learned element to depression and a glance through one’s own family tree might show a pattern to depression – which may indicate both genetic and learned factors. ‘Grumpy Old Grandpa’ may well have been suffering from depression which may have had a genetic element but may also have given his child a pervasive feeling that ‘the world is rather a miserable place’, and so on. All is not lost – it’s quite possible to break the cycle! Other factors considered to render one vulnerable to depression include: poor social support; difficult/abusive early experience; and low self-esteem. It is well recognized that disturbances in the action of neurotransmitters contribute to triggering and maintaining, and in turn are maintained by, depressive illness and the majority of anti-depressant medications work on neuro-transmitter action.

Lifespan, Gender and Depression

It can be useful to think of lifespan, gender, transitional and development issues when thinking about depression. Postnatal depression is linked to the period of after the birth of a child and can be debilitating and upsetting illness, at a time when most people would expect to be feeling particularly happy. Difficulties negotiating times of transition and hormonal changes can both contribute to triggering a depressive episode. Some illnesses, such as Alzheimer’s disease, kidney disease, low thyroid function and viral illness, for example influenza and herpes, cause depression and it is always worth considering other illnesses when making the diagnosis and it is always worth considering other illnesses when making the diagnosis. Many medications cause depression as a side effect (always read the accompanying literature with prescription drugs). This is why your GP may consider a physical examination and perhaps blood tests before recommending a treatment package. Whilst it is commonly known that a greater number of women present with depression, there is some evidence to suggest that this may be because men are less likely to present to professionals with depression for a number of reasons.

Unfortunately, for many people the idea that their depression is other than a physical illness treatable by anything other than medication, or indeed needing no treatment at all, is difficult. It should be noted that the National Service Framework recommends that the optimum treatment package for depression would be a course of medication alongside a course of cognitive behavioural therapy.

When To Get Help?

If you have been feeling low in mood for more than a month, are finding that your mood is impacting significantly on your life and are experiencing symptoms of depression as described above (nobody will by any means have all of them!) you should talk to someone else about it and consider contacting your GP. Some professionals, confusingly perhaps, refer to some of the symptoms as ‘biological’ symptoms which serve to help to confirm a ‘definite diagnosis’ of depression. Certainly, a pattern of early morning waking, loss of libido, sleep difficulties and change in appetite would indicate to most professionals that their client is unwell with depressive symptoms. You should seek help immediately if you are experiencing suicidal thoughts, with your GP being your first port of call.

How To Get Help?

It’s true that many people with depression get better without intervention. Nevertheless, it’s important that you don’t feel you have to ‘grin and bear it’ or ‘put on a brave face’ – there is help available and nobody should feel they have to go through this debilitating illness alone.

People with depression will need varying degrees of help. The NHS has recognized the importance of timely and appropriate interventions for depression. The NICE (National Institute for Clinical Excellence) guidelines (www.nice.org.uk – a website well worth looking at) recommend a stepped care approach with the initial three (of five steps) right up to moderate and severe depression being primary-care based (e.g. GP – surgery based). A Community Mental Health Team referral is recommended at Stage 4 for, for example, ‘atypical’ depression, complex difficulties, a high level of rish (e.g. of killing yourself or harming others), psychosis with depression or ‘treatment-resistant’ depression.

Often the thing to do is to talk to someone close to you – they might even have recognized changes in you and be worried about you already.

Once you, or those around you, have recognized that you are ill and have plucked up courage to seek help, there is an excellent chance that you will get better a lot quicker than if you left it to ‘Old Father Time’. Remember, many GPs, film stars, shop assistants, company directors will have had, or will experience, an episode of psychological illness in their lifetime – it’s just that, perhaps unfortunately, not many people talk about it.

Your first port of all should, ideally, be your GP. Remember a GP has around seven minutes per consultation and you need to be clear about exactly how bad you feel and what your symptoms are. Try to give him/her all the information you can, maybe bringing a list of symptoms to the meeting. It might be helpful to take someone along with you to the surgery. If the initial consultation doesn’t go quite as you planned – maybe your GP doesn’t seem to understand – don’t worry or lose hope; make another appointment or, if there is one, try another GP in your surgery. Some GPs are much more psychologically minded than others and it may be worth finding one you feel you work well with. But remember, GPs are trained to recognize and treat the symptoms of depression so you should be able to get the treatment you need.

What Kind of Help Is Available?

You and your GP can consider the options which may include medication and/or psychological therapy, a referral to the Community Mental Health Team, or perhaps, initially, a brief ‘wait and see’ or ‘watchful waiting’ approach. A referral to the CMHT would normally be offered after a period of GP-based treatment and consultation, if things are not moving forward for you after some time of surgery-based treatment. In very severe long-term or chronic cases you may be offered ECT – electro-convulsive therapy – following onward referral from your GP. This was once the stuff of One Flew Over the Cuckoo’s Nest nightmares but times have moved on. Whilst nobody knows precisely how it works, ECT has been shown to have a positive effect in ninety percent of cases. Much more typically, you may start on a course of anti-depressant medication. It’s important to note that anti-depressant medication takes a few weeks to take effect. Be cautious as always when responding to press articles about medications and discuss these with your GP before making any decisions.

Onward Referrals – What Else Might Happen After A Visit To Your GP?

If you are lucky enough to live in an area with in-surgery psychological help or counselling available you could then be offered a short course of counselling/psychotherapy to help you look at ways of understanding and working your way out of / coping with depression. Alternatively, you may be referred to your local Community Mental Health Team. Your local CMHT can make onward referrals if necessary, for example for highly specialized psychological treatment. The referral from your GP surgery will usually be allocated to an appropriate member / members of the CMHT who are all likely to have been trained in mental health issues, regardless of their title. Normally you would then be ‘assessed’ by a member / members of the team and the most appropriate care package (referred to as the Care Plan Approach (CPA)) would be worked out between yourself, your carers (if appropriate) and members of the team. This may include ‘talking treatments’ / psychotherapy. It is possible, also, that at any stage various types of self-help literature might be recommended to you to work through (either on your own or with support) and in some areas there are opportunities to use computer-based self-help programmes. Sometimes, group psychotherapeutic treatment is offered. In cases of severe depression, the norm is to use hospital as a last resort and to work towards building a care programme for you in the community.

Help Outside the Statutory Services – i.e. the NHS

There are, of course, non-statutory agencies that you can involve in your care either in addition to or, sometimes, instead of the care you might be offered within the NHS. You can also seek private psychiatric and psychological treatment. Again, you should think about discussing a private referral with your GP. On another note, it is important to check what will and will not be paid for before doing this if you have health insurance – some insurers put a limit on psychological treatment. In terms of psychological help there are many private psychologists, psychotherapists and counsellors available with varying levels of fees. You can also consider a referral to a private psychiatrist after a discussion with your GP.

Complementary Medicine and Helping Yourself

You may also think about complementary medicine such as taking fish oils or St. John’s Wort, visiting an acupuncturist, and so on. Again, it is worth discussing these interventions with your GP.

St. John’s Wort is a mild herbal anti-depressant available from pharmacists without a prescription in the UK. It can be useful, but nonetheless it can still lead to hypomania and it does interact with a number of other medications.

It can be hard to have good insight into depression. Long-standing depression can be unremarkable as the wallpaper; some people just feel a bit low all the time and like to try to help themselves. By all means try St. John’s Wort, but remember that you will not be able to get it on prescription. It is still important to have some experienced input into your mental health, possibly from your GP, your psychiatrist or your community psychiatric team. Finally, you will have to pay for St. John’s Wort but for some people it is worth the price so they feel in control.

Certainly there are many ways you can improve your chances of a speedy recovery including:

• Taking exercise
• Cutting out / down alcohol / street drugs
• Building positive activities into your day
• Eating well
• Cutting down caffeine intake
• Drinking plenty of water
• Talking to others
• Seeing other people
• Sorting out any physical problems
• Taking care of your appearance
• Taking up yoga etc.
• Recognizing and challenging negative thought patterns.

Depression and Those Around You

Depression is a difficult illness both for those experiencing the debilitating effect on their physical and mental well-being and for those around them. It is, for example, sometimes difficult to even think of a time when you felt happy. Others may feel they have forgotten what you are like when you do not have depressive symptoms. It is important for those who are spending long periods of time with someone who is depressed, as well as offering understanding, patience, listening and support, to make time for themselves – to nurture themselves and to remember that depression is an illness that, in the vast majority of cases, will pass. If the person you care for has been referred to a CMHT, you can also request a carer’s assessment which may be helpful.

Keep Trying

The first step in fighting depression is recognizing it and deciding to seek help. Sometimes getting help can be difficult in itself and you may need to keep trying. You are not alone. Depression is, in the majority of cases, eminently treatable, and the sooner you can begin to access help, both social and professional, the shorter this debilitating illness is likely to last.