Depression – A Guide

Depression is often an illness. Depressive illness makes the usual feelings of sadness that we all experience temporarily remain for weeks, months or even longer periods of time. They can be so intense that daily life is affected. You can’t work normally, you don’t want to be with your family and friends, and you stop enjoying the things you usually do.

See also: Depression and Low Mood Products

If you’re depressed, you may feel worthless, hopeless and constantly tired. In most cases, if you have milder depression, you can probably carry on but will find everyday tasks difficult. If you have severe depression, you may find your feelings so unbearable that you start thinking about suicide.

About one in 10 of us develops some form of depression in our lives, and one in 50 has severe depression. It affects not only those with depression, but also their families and friends.

The good news is that with the right treatment and support, most depressed people make a full recovery. It’s important to seek help from your GP if you think you may be depressed.

If you’re feeling suicidal or in a crisis of depression, contact your GP as soon as possible.

If you can’t, or don’t want to speak to your GP about it, contact the Samaritans on 08457 909090. The lines are open 24 hours a day, seven days a week. Alternatively, visit the Samaritans website

Knowing the symptoms

If you’re depressed you often lose interest in things that you used to enjoy. Depression commonly interferes with your work, social and family life. In addition, there are many other symptoms, which can be physical, psychological and social.

Psychological symptoms:

• continuous low mood or sadness,
• feelings of hopelessness and helplessness,
• low self-esteem,
• tearfulness,
• feelings of guilt,
• feeling irritable and intolerant of others,
• lack of motivation and little interest in things,
• difficulty making decisions,
• lack of enjoyment,
• suicidal thoughts or thoughts of harming someone else,
• feeling anxious or worried, and
• reduced sex drive.

Physical symptoms:

• slowed movement or speech,
• change in appetite or weight (usually decreased, but sometimes increased),
• constipation,
• unexplained aches and pains,
• lack of energy or lack of interest in sex,
• changes to the menstrual cycle, and
• disturbed sleep patterns (for example, problems going to sleep or waking in the early hours of the morning).

Social symptoms:

• not performing well at work,
• taking part in fewer social activities and avoiding contact with friends,
• reduced hobbies and interests, and
• difficulties in home and family life.

Grief and depression

Even though grief and depression share many of the same characteristics, there are important differences between them. Grief is an entirely natural response to a loss, while depression is an illness. However, sometimes, it can be hard to distinguish between feelings of grief and depression.

People who are grieving find that feelings of loss and sadness come in waves, but they are still able to enjoy things and are able to look forward to the future. However, those who are depressed have a constant feeling of sadness; they do not enjoy anything and have little sense of a positive future.

Causes

There are many different factors that can trigger depression. For some people, upsetting or stressful life events, such as bereavement, divorce, illness, redundancy, and job or money worries, can be the cause.

This is often known as ‘reactive depression’, where depression is a reaction to the event. In other cases, depression does not have an obvious cause.

As depression can have many causes, it is sometimes divided into three broad groups – psychological, physical and social.

Psychological – this is where a stressful or upsetting life event causes a persistent low mood, low self-esteem and feelings of hopelessness about the future

Physical or chemical – depression is caused by changes in levels of chemicals in the brain. For example, your mood can change as hormone levels go up and down. This is often seen in women as it is associated with the menstrual cycle, pregnancy, miscarriage, childbirth and the menopause.

Social – doing fewer activities or having fewer interests can cause depression, or may happen because of depression.

Family History

If you have a family history of depression, you are more likely to get depression yourself.

Diagnosing depression

If you think you have depression, you should visit your GP. Your GP may give you a physical examination and do some blood or urine tests to rule out other conditions that have similar symptoms, such as under-active thyroid.

There are no clinical tests for depression, so detailed interviews and questionnaires are usually used to make a diagnosis.

There are many different questionnaires used to measure depression. However, two classifications of mental illness are most widely used:

Diagnostic and Statistical Manual of Mental Disorders. This is a classification system based on all the known recorded symptoms associated with a particular mental condition. Your GP will ask you if you have certain symptoms, and depending on your answers, will be able to use the system to identify what the condition is.

International Classification of Diseases. This is a similar system of classifications, again based on the known symptoms associated with particular diseases. Developed by the World Health Organization, it is a much wider system, covering all diseases (not just mental health). Your GP will ask you about your symptoms in order to classify your condition.

Using one of these two guidelines, it is usually possible for your GP to diagnose depression, decide which type of depression you are experiencing, and to rule out other mental conditions.

Any discussion that you have with your GP about your depression will be treated in the strictest of confidence. Your GP will only ever break this rule if there is a significant risk of harm to either yourself or to others, and if informing a family member or carer would reduce that risk.

Is it my fault that I have become depressed?

It is definitely not your fault. It may be difficult to avoid it, but there are certainly things you can learn to do to recognise depression early so you can avoid becoming more severely ill.

If you have had depression before, this would involve learning how to recognise your early warning signs. Everyone has their own particular early warning signs, such as not sleeping properly, starting to brood about things, or spending all your time working and not enjoying yourself.

You learn that when you have these early warning signs, you have to reflect on your lifestyle and make changes where necessary.

Can I continue working?

If your depression is caused by overwork, or is affecting your ability to do your job, you may need a little time off to recover. However, there is evidence that taking prolonged time off work can make depression worse. The Department for Work and Pensions found that if you take more than a year off work for a mental health problem, you stand a greater chance of dying than of ever going back to work. In fact, there is quite a lot of evidence that going back to work can help you recover from depression.

Treating depression

Does depression return?

You can make a full recovery with treatment, but there is a risk that your depression will return. About half of the people who have a first episode of depression will have another episode within 10 years. The risk of further bouts of depression for these people is higher than in someone who has never been depressed, and more likely if treatment is not continued for the prescribed period of time.

Treatment for depression usually involves a combination of drugs, talking therapies and self help. Hardly anyone with depression is admitted to a psychiatric hospital. Most get treatment from their GP and make a good recovery.

Mild depression

• If you are diagnosed with mild depression but your GP thinks you’ll improve, you can have another assessment in two weeks’ time to monitor your progress. This is known as ‘watchful waiting’.
• Antidepressants are not usually recommended as a first treatment.
• Exercise seems to help some people. While your progress is being monitored, your GP may refer you to an exercise scheme with a qualified fitness trainer.
• Talking through your feelings may also be helpful. You may wish to talk to a friend or relative, or your GP may suggest a local self-help group.
• Your GP may recommend self-help books and computerised cognitive behaviour therapy (CBT) (see below for further details).

Chronic mild depression (present for two years or more) is called dysthymia. This is more likely in people over 55 years and can be difficult to treat. If you are diagnosed with dysthymia, your GP may suggest that you start a course of antidepressants.

Moderate depression

• If you have mild depression that is not improving, or you have moderate depression, your GP may recommend a ‘talking treatment’ or prescribe an antidepressant (see below for further details).

Severe depression

• Your GP may recommend that you take an antidepressant, together with talking therapy. A combination of an antidepressant and cognitive behavioural therapy (CBT) usually works better than having just one of these treatments.
• You may be referred to a mental health team. These teams are usually made up of psychologists, psychiatrists, specialist nurses and occupational therapists. They often provide intensive specialist talking treatments, such as psychotherapy.

Talking treatments

Cognitive behavioural therapy (CBT)

You normally have a fixed number of sessions – usually six to eight sessions over 10-12 weeks. Some GP practices have counsellors specifically to help patients with depression.

CBT is based on the principle that the way we feel is partly dependent on the way we think about things. It teaches you to behave in ways that challenge negative thoughts – for example, being active to challenge feelings of hopelessness.

Interpersonal therapy (IPT)

IPT focuses on your relationships with other people and on problems, such as difficulties with communication or coping with bereavement. There is some evidence that IPT can be as effective as medication or CBT, but more research is needed.

Counselling

Counselling is a form of therapy that helps you to think about the problems you are experiencing in your life, in order to find new ways of dealing with them. Counsellors support you in finding solutions to problems, but do not tell you what to do.

Antidepressants

Antidepressants take two to four weeks to take effect. If the first antidepressant you try is not effective or causes side effects, it may be necessary to change the dose. Sometimes, a different type of antidepressant will be recommended.

Your GP or specialist nurse should see you every one to two weeks when you start taking antidepressants. You should continue taking the antidepressants for at least four weeks (six weeks if you are elderly) to see how well they are working. If your antidepressants are working, treatment should be continued at the same dose for at least four to six months (12 months if you are elderly) after your symptoms have eased. If you have a history of depression, you should continue to receive antidepressants for up to five years, or longer.

Antidepressants are not addictive but withdrawal symptoms are quite common if you stop taking them suddenly, or you miss a dose.

SSRI’s

If your GP thinks you would benefit from taking an antidepressant, you will usually be prescribed an SSRI (selective serotonin reuptake inhibitor).These are as effective as the older TCAs (tricyclic antidepressants) and have fewer side effects. Fluoxetine, citalopram and sertraline are all examples of SSRIs.

SSRIs increase the level of a natural chemical in your brain called serotonin, which helps to lift your mood. You may have some side effects when you start taking SSRIs, such as nausea, headache, sleep problems and anxiety. However, these tend to improve over time.

Some SSRIs should not be prescribed for children under the age of 18 years. Research shows that the risk of self-harm and suicidal behaviour may increase if they are used to treat depression in this age range. Fluoxetine is the only SSRI that may be prescribed for under-18s, but only when specialist advice has been given.

Other antidepressants

These include:

• TCAs (tricyclic antidepressants), such as dothiepin, imipramine and amitryptyline. These are used to treat moderate to severe depression. They work by raising the levels of the chemicals serotonin and noradrenaline in your brain, which both help to lift your mood. You should not smoke cannabis if you are taking TCAs because it can cause your heart to beat rapidly.
• MAOIs (monoamine oxidase inhibitors), such as phenelzine sulphate, is sometimes used to treat ‘atypical depression’. This is when you tend to eat and sleep more than usual. You should not smoke cannabis if you are taking MAOIs because it may affect the way these medicines work, and it is not clear what effect this may have on you.
• New antidepressants, such as venlafaxine, nefazodone, and mirtazapine, work in a slightly different way from SSRIs and tricyclics. These drugs are known as SSNIs (Serotonin-norepinephrine reuptake inhibitors). Like TCAs, these antidepressants work by changing the levels of serotonin and noradrenaline in your brain. Studies have shown that a SSNI like venlafaxine can be more effective than a SSRI, though it is not routinely prescribed as it can lead to a rise in blood pressure.

St John’s wort

St John’s wort is a herbal treatment that some people take for depression. Though there is some evidence that it may be of benefit in treating mild or moderate depression, its use is not recommended. This is because the quantity of its active ingredients vary among individual brands and batches, so it is uncertain what sort of effect it could have on you.

Taking St John’s wort with other medications, such as anticonvulsants, anticoagulants, antidepressants and the contraceptive pill, can also cause serious problems.

You should not use St John’s wort if you are pregnant or breastfeeding as there is not enough evidence that its use is safe in these situations.

Electroconvulsive therapy (ECT)

Sometimes, other treatments, such as specialist medicines or electroconvulsive therapy (ECT), may be advised if you have severe depression. Electroconvulsive therapy (ECT) works for severe depression, but it is only used when antidepressants and other treatments have not worked.

If ECT is recommended for you, you will first be given an anaesthetic and medication to relax your muscles. You will then receive an electrical ‘shock’ to your brain through electrodes placed on your head. You may be given a series of ECT sessions. For most people, the treatment works well in relieving severe depression, but the effect may not be permanent. Some people may experience unpleasant side effects, including memory problems.

Lithium

If you have tried several different antidepressants and have experienced no improvement, your doctor may offer you a type of medication called lithium, in addition to your current treatment.

There are two types of lithium – lithium carbonate and lithium citrate. Both are usually effective, but if you are taking one that is effective, it is best not to change. In order to work, you have to have a certain level of lithium in your blood. If this level becomes too high, the lithium can become toxic. Therefore you will need blood tests every three months to check your lithium levels. You should also avoid going on a low-salt diet because this can also cause the lithium to become toxic – consult your GP for advice about your diet.

Before you start taking lithium, you should have an electrocardiograph (ECG) to check your heart

Suicide and depression

Mental disorders, particularly depression and substance abuse, are associated with more than 90% of all cases of suicide.

The warning signs of suicide

Some of the warning signs that people with depression are considering suicide are:

• Making final arrangements – such as giving away possessions, making a will or saying goodbye to friends.
• Talking about death or suicide – this may be a direct statement, such as ‘I wish I was dead’, but often depressed people will talk about the subject indirectly, using phrases like, ‘I think dead people must be happier than us’, or ‘wouldn’t it be nice to go to sleep and never wake up’.
• Self-harm – such as cutting their arms or legs, or burning themselves with cigarettes.
• A sudden lifting of mood – this could mean that a person has decided to commit suicide and feels better because of this decision.

Helping a suicidal friend or relative

If you see any of the above warning signs, you should:

• get professional help for the person,
• let them know they are not alone and you care about them, and
• offer your support in finding other solutions to their problems.

If you feel that there is an immediate danger, stay with the person or have someone stay with them, and remove all available means to suicide. The most obvious means is medication. Over-the-counter drugs such as painkillers can be just as dangerous as prescription medication. Also, remove sharp objects and poisonous household chemicals like bleach.

Helping yourself and Support Groups

If you feel you may be suffering from mild to moderate mental illness, there are lots of organisations to give you the support and advice you need. The NHS, voluntary organisations and private organisations can all help.

Visit your family doctor to find out if general counselling is available in your area. Your GP can advise whether a referral would help you. If you’re having relationship or marriage difficulties, contact Relate (0845 130 4010). Its counsellors can talk things through with you and your partner. You will normally be expected to pay a fee to cover the costs of the sessions, although some Relate centres offer subsidies.

The mental heath charity SANE has a dedicated helpline on 0845 767 8000. The service offers practical information, crisis care and emotional support. It is open from 1pm to 11pm, every day.

Samaritans:

tel: UK dial 08457 90 90 90
Republic of Ireland dial 1850 60 90 90

Preventing depression

To deal with depression, and help prevent repeated bouts of depression, you should:

• take your medicines regularly as directed, without skipping any days,
• discuss reducing or stopping medication with your GP before you make any changes,
• gradually try to increase the activities that you enjoy,
• avoid smoking, illegal drugs and alcohol – these may seem to make you feel better in the short term, but can make you feel worse in the long term,
• use a problem-solving approach to deal with stress and worry,
• try to identify negative thoughts and change them to positive thoughts,
• assess your symptoms regularly and consult your GP or counsellor if problems arise,
• increase the amount of exercise that you do – this can trigger the release of the brain chemical serotonin, which boosts your mood,
• learn how to relax using relaxation exercises and tapes,
• practice yoga, meditation or have a massage to help relieve tension and anxiety, and
• join a self-help group and discuss your feelings and concerns – it can help you to feel less isolate

Depression and diet

There is increasing evidence that changes in your diet can help prevent depression occurring, or if you are depressed, can help in the treatment of your depression.

Omega-3 fatty acid:

Research has shown a link between the amount of a fish people in different countries eat and the level of depression. In Japan, where people eat on average 70kg (150lbs) of fish a year, the rate of depression is 0.12%. Whereas in New Zealand, where people eat only 18kg (40lbs) of fish a year, the rate of depression is almost 50 times higher.

It is though that a chemical found in fish – omega-3 fatty acid – may help your brain work more efficiently, so serotonin (which can boost your mood) has more of an effect on you.

Fish that contains a lot of omega-3 fatty acid includes salmon, sardines and mackerel. Vegetarian alternatives include walnuts and tofu, and omega-3 food supplements are also available over the counter (OTC) from health shops.

Protein and serotonin:
Serotonin is made up of an amino acid called 5-HTP, which is made from another amino acid called tryptophan. Both of these are found in protein-rich foods, such as meat, fish, beans and eggs. Foods also high in vitamin B, such as bananas and avocados, can be beneficial to your mood as they convert tryptophan into serotonin. By eating these types of food, you are helping your body to produce more serotonin and it can therefore boost your mood.

Bad-mood food:Alcohol, caffeine, sugar, chocolate, cakes, biscuits, cheese and bread are the most common types of foods that cause low moods. Sugar is a major cause of altering mood because when you eat something sugary, your blood sugar level rises sharply, which is followed about an hour or so later by a ‘sugar low’, as the amount of sugar in your blood decreases. This has a negative effect on your mood and energy level, leading to poor concentration, anxiety, irritability, aggression, tiredness and depression.