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What you should know about depression

By Randima Attygalle
Socio-economic strains in life have a direct impact on the psychology of human beings, very often resulting in stress. When life’s stressful situations reach their apex and the human brain is unable to ‘cope’ any more, depression is inevitable.

Any person irrespective of gender or age could contract depression, which is one of the most traumatic and commonest mental conditions. Consultant Psychiatrist, Dr. Neil Fernando spoke to The Nation on the importance of identifying symptoms of depression in a person and administering professional medical treatment.
“Depression is three-fold. It could be presented as a normal emotion, as a symptom of another illness or depression itself as a disorder,” explained Dr. Fernando, highlighting the three broad divisions of depression.

Depression as a normal emotion

“Everyone single of us has become depressed from time to time owing to day to day incidents in life. Just like experiencing happiness or sorrow, a person could experience depression, which of course will pass in a day or two. This is not an illness as such. For example, after the delivery of a baby, new mothers sometimes experience an emotion commonly called ‘baby blues,’ which dies off in a few days,” explained Dr. Fernando.

Depression as a symptom of another illness

“This is where depression could occur as a symptom of another illness and not as the primary illness. For instance, after a viral infection, many people pass through a phase of depression. Many cancer patients initially present the ailment as depression although the underlying illness is cancer,” explained Dr. Fernando, who further said that even in cases of hormonal changes and metabolic diseases, a presentation of depression is visible.

Depression as an illness

“This is a condition referred to as depressive disorder. Among psychiatrist disorders, depressive disorder is one of the commonest. So common, that in laymen’s language it is called the ‘common cold’ of the psychiatrist,” explained Dr. Fernando.

According to Dr. Fernando, females are more prone to depression – one in every four females experience depression at some point in life. “There are many theories put forward as to why females are more prone. One such theory is that male depression is drowned in other external factors such as alcohol, thus it not being as visible as in females. The other theory is that females are generally exposed to stressful events in life,” said Dr. Fernando.

Causes of depression Pre-disposing factors

“Pre-disposing factors are those which make a person more vulnerable to depression. A person could be either genetically pre-disposed to develop depression or other physical and psychological factors could contribute,” elaborated Dr. Fernando, adding that childhood trauma can make a person pre-disposed to depression later in life. “Physical abuse, sexual abuse, psychological abuse or psychological trauma resulting in parental-separation, can make a person pre-disposed to depression,” explained he.

Precipitating factors

According to Dr. Fernando, these factors are useful in causing disorder at a particular time in a vulnerable person. Precipitating factors could be associated with day-to-day events like work-related stress, failures, domestic stress and even a physical illness.

Maintaining or perpetuating factors

“Marital disharmony and work-related stress are some of the commonest perpetuating factors which will continue to keep a person in a depressed stage, which impedes recovery. We often see a relapse when such patients are introduced back to the familiar surroundings, either at home or at work place, after treatment,” explained Dr. Fernando.

Identifying depression

“Unlike in the West, in our society there is a stigma attached to depression as many are ignorant of the distinction between insanity and depression. Therefore many depressed patients are reluctant to seek professional treatment in fear of being ridiculed by society,” explained Dr. Fernando, who emphasised on the dire need to identify symptoms of depression and treat it like any other illness.

“Strictly speaking, depression is a disorder in the brain, so it should not be considered extraordinary; like any other ailment, it should be treated,” explained Dr. Fernando, who further said that the penalty for neglecting it could be fatal.

“Depression can end up in death. Recent studies on suicide revealed that the majority of those who had committed suicide were depressed and the depression had not been recognised on time,” said Dr. Fernando.
“Very few local patients will openly admit to a physician that he/she is depressed. They often come with physical complaints that are part of the depressive illness. The danger of it is that physicians may not sometimes pick up the real illness, as the patient would generally visit the family doctor or a physician and not a psychiatrist. Therefore it is important that immediate family members or close friends identify symptoms of depression, so that they could be directed to psychiatric treatment,” emphasised Dr. Fernando.
Biological symptoms of depression

• Disrupted sleep (occasionally there are depressed people who have excessive sleep. Such cases are rare)
• Loss of appetite (there is a very low percentage of excessive eaters)
• Significant weight loss
• Complains of headaches, fatigue, aches and pains
• Reduced libido or loss of interest in sexual life
Psychological symptoms
• Mood disorders. A depressed person will always be in low spirits
• Feeling of sadness and rejection
• Harbouring suicidal ideas. There can be agitation and violence in a depressed person to the extent of committing suicide
• Inability to enjoy life and loss of pleasure
• Guilt about past events. There is a tendency to blame oneself. Insignificant omissions or commissions are dwelt upon
• Pessimistic outlook on life
• Loss of interest in life and developing self-depreciatory ideas
Depression in children and elderly people
“Depression can occur at any age, although the presentation could be different. Very often, impaired memory is attributed to old age, but it could be a symptom of depression in elderly people,” explained Dr. Fernando, who outlined poor performance in studies and sports, misbehaviour and difficulties in concentration as some of the chief symptoms of depression in children.

Family responsibility

“Depression is one of the most disabling and traumatic illnesses. Depressed people are so disabled that they often feel ending life is a relief. It is so distressing that even after recovery, the main request of the patient from the psychiatrist is to ensure he or she would never experience it again,” explained Dr. Fernando, adding that family support is paramount in this regard. According to Dr. Fernando, signs of depression such as lowered eye gaze, wrinkling of the forehead, sighing and tearful looks are often misinterpreted. “These could be symptoms of depression which you cannot take lightly as normal emotion which would die away in time. Prolonged depression will cause more trauma to the patient. Therefore early treatment is important,” explained Dr. Fernando.

Cost-effective treatment

According to Dr. Fernando, treatment for depression is relatively less costly. “Compared to other kinds of treatment, depression does not require very costly methods. However it should be a fusion of physical and psychological treatment.”

Anti-depressant drugs

Depression is a result of a chemical change in the brain or a chemical imbalance in the neuro transmitters in the brain. The anti-depressant drugs correct this imbalance. “It is important that a course of such drugs is continued properly, (minimum period is six to nine months) or else there is a risk of a re-lapse,” emphasised Dr. Fernando.
Electro Convulsive Therapy (ECT)
This is a method by which an external source of calculated electrical energy is passed through the brain to alter the chemical imbalance which causes depression. Quick results and minimal side effects are the chief advantages of ECT.

“Though anti-depressant drugs are effective, they take at least two weeks to start reacting. The advantage of ECT is that it can be administered on very severely depressed patients, so that quick results could be obtained,” explained Dr. Fernando.
Highly suicidal parents and females experiencing depressive disorders after childbirth are often administered ECT, according to Dr. Fernando. “ECT can be called a life-saving method. For instance, when ECT is given to new mothers who are experiencing depressive disorders after child birth, it saves the life of the newborn as well because when the mother’s health is impaired, the child will naturally suffer.”

Cognitive behaviour therapy

“The underlying principle of cognitive behaviour therapy is to change the way of thinking. Since the behaviour of a person is fashioned on his/her thinking, the latter would undoubtedly reflect in the behaviour. Evidence-based research had shown that this therapy is as effective as drug treatment,” elaborated Dr. Fernando, stressing on the importance of it being carried out by professionals trained in cognitive behaviour therapy.

Social treatment

This is where family-care plays a major role. Unlike in a physical illness where the patient is often encouraged to rest, depression on the other hand encourages interaction. “We always encourage patients to engage in some activity so that dwelling on depressive thoughts would be avoided. Even sharing thoughts with a close friend or relative is useful,” explained Dr. Fernando.

Social factors contributing to depression

Population structure, war culture, migration, competitive life style, domestic violence, work related stress and increase abuse of alcohol can be identified as major social factors contributing to depression.
Population structure
“If we consider the social structure in the country, we have two age groups that are rapidly expanding – young adults between the age of 15 and 30 and adults over 60. Mental illnesses are at its highest among these two age groups,” explained Dr. Fernando.

War culture

“The insurrections and the civil war experienced by Sri Lankans have also been instrumental in causing depression. Not only those who are in the battlefront, but also their family members, especially parents, spouses and children experience what is known as combat-related depression. War could be psychologically very traumatic, even for those exposed to war in threatened areas,” Dr. Fernando said.

Migration

There is lot of internal migration owing to an array of reasons. Migration due to war, development and employment are noteworthy in this regard. According to Dr. Fernando, removal from their ‘known surroundings’ and family unit could cause depression. “This affects not only the individual going away from such surroundings but also those who are left behind such as children and spouse,” Dr. Fernando emphasised. The change of lifestyles in a competitive society has accelerated depression according to Dr. Fernando. “Even the education system is very competitive, subjecting children to a lot of stress. The traditional way of life has changed radically, making more individuals prone to life’s stresses, which in the long run can cause depression,” said Dr. Fernando, emphasising the importance of seeking professional psychiatric treatment in such situations.

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Depression in the elderly

By Usha Perera
Sri Lanka is a fast ageing society and it is estimated that by year 2020, 60% of the population in Sri Lanka will belong to the elderly group. As such, it is important for caregivers and health personnel to be knowledgeable about health problems of the elderly.
Depression in the elderly frequently coexists with other medical illnesses and disabilities. In addition, advancing age is often accompanied by loss of key social support systems due to the death of a spouse or siblings, retirement, and/or relocation of residence.
Because of their change in circumstances and the fact that they’re expected to slow down, doctors and family may miss the diagnosis of depression in elderly people, delaying effective treatment. As a result, many seniors find themselves having to cope with symptoms that could otherwise be easily treated
Depression tends to last longer in elderly adults. It also increases their risk of death. Studies of nursing home patients with physical illnesses have shown that the presence of depression substantially increased the likelihood of death from those illnesses.
Depression has also been associated with increased risk of death following a heart attack. For that reason, making sure that an elderly person you are concerned about is evaluated and treated is important, even if the depression is mild.
Risk factors
Factors that increase the risk of depression in the elderly include: being female, unmarried (especially if widowed), stressful life events, and lack of a supportive social network. Having physical conditions like stroke, cancer and dementia further increases that risk. While depression may be an effect of certain health problems, it can also increase a person’s risk of developing other illnesses – primarily those affecting the immune system, like infections.
The following risk factors for depression are often seen in the elderly:
• Certain medicines or combination of medicines
• Other illnesses
• Living alone, social isolation
• Recent bereavement
• Presence of chronic or severe pain
• Damage to body image (from amputation, cancer surgery,
or heart attack)
• Fear of death
• Previous history of depression
• Family history of major depressive disorder
• Past suicide attempt(s)
• Substance abuse
There are several treatment options available for depression.
Antidepressant medicines
Many antidepressant medicines are available to treat depression. Most of the available antidepressants are believed to be equally effective in elderly adults, but the risk of side effects or potential reactions with other medicines must be carefully considered. For example, certain traditional antidepressants – such as amitriptyline and imipramine – can be sedating and cause a sudden drop in blood pressure when a person stands up, which can lead to falls and fractures.
Antidepressants may take longer to start working in older people than they do in younger people. Since elderly people are more sensitive to medicines, doctors may prescribe lower doses at first. Another factor may be forgetting (or not wanting) to take their medicine. Many elderly patients are taking lots of drugs, which can lead to increased complications and side effects. In general, the length of treatment for depression in the elderly is longer than it is in younger patients.
Facts
• Recent research shows that elderly women who have a vitamin B-12 deficiency are twice as likely to be severely depressed as those without this deficiency.
• People who are depressed often have poor eating habits, so it is difficult to determine whether the vitamin deficiency is a cause or result of depression.
• Some doctors say they often recommend that depressed patients try to improve their eating habits and take a multivitamin, along with other treatments
Psychotherapy
Most depressed people find that support from family and friends, involvement in self-help and support groups, and psychotherapy are very helpful. Psychotherapy is a method of treatment that relies on a unique relationship between a therapist and his or her patient. The goal of psychotherapy is to discuss issues and problems in order to eliminate or control troubling and painful symptoms, helping the patient return to normal functioning.
It could also be used to help a person overcome a specific problem or to stimulate overall emotional growth and healing. In regularly scheduled sessions, usually 45 to 50 minutes in length, a patient works with a psychiatrist or other therapist to identify, learn to manage, and ultimately overcome, emotional and behavioural problems.
Psychotherapy is especially beneficial for those patients who prefer not to take medicine, as well as for those not suitable for treatment with drugs because of side effects, interactions with other medicines, or other medical illnesses. The use of psychotherapy in older adults is especially beneficial because of the broad range of functional and social consequences of depression in this age group. Many doctors recommend the use of psychotherapy in combination with antidepressant medicines.
Electroconvulsive Therapy (ECT)
Electroconvulsive therapy (ECT) plays an important role in the treatment of depression in older adults. ECT is a medical treatment performed only by highly skilled health care professionals, including doctors and nurses, under the direct supervision of a psychiatrist
Other problems
The stigma attached to mental illness and psychiatric treatment is even more powerful among the elderly and is often shared by members of the patient’s family, friends, and neighbours. This stigma can keep elderly patients from seeking treatment. In addition, depressed older people may not report their depression because they believe there is no hope for help. This sense of helplessness is a characteristic of the disease itself.
Elderly people may also not be willing to take their medicines because of side effects or cost. In addition, having certain other illnesses at the same time as depression can interfere with the effectiveness of antidepressant medicines. Therefore it is important for the caregivers or family members to see that the drugs are taken consistently. It is also important to treat the elderly with compassion.

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Famous people who beat depression

Abraham Lincoln:
From his mid-20s, Abraham Lincoln was recognised by his closest friends as a person afflicted with melancholia, termed as depression today. His lowest points were so intense that they had to take razors away from him and even lock him up to protect him from injuring himself.
In the early 1840s, he suffered a second attack of depression that set him permanently on a pattern of illness which left Lincoln under the daily care of a doctor for a period and subject to the medications of the time, including cocaine, mercury, camphor and sarsaparilla.  His friends would watch as he would sit quietly in a corner, far far away from the levity and good times around him.
Some say that the causes of these two episodes were intense work, problems with women and the sad harshness of the weather. But actually, we do not know what causes depression – Lincoln’s, Churchill’s or that of other people.
He went on to become successful as a state politician and then as a corporate lawyer, and in the late 1840s, he totally devoted himself to making money and avoiding politics. But with the passage of the Kansas-Nebraska Act of 1850, Lincoln clearly saw that slavery would become a national institution, sweeping across the republic, and he made a career out of exposing its moral hollowness. Time and time again, audiences saw the tall, sad-looking speaker, and were so transformed by his personal outrage on the issue of slavery that he became a compelling figure in the new Republican Party.
Lincoln used humor, ribald stories, epigrams and the Bible as ways to draw off the poison of melancholy, and those efforts gave him a warm and even beloved temperament. He was not a religiously orthodox man, but he believed in fate, denied that man could be redeemed, thought that human improvement on earth was still possible, and insisted that determined effort could help him control armies and some events.
Lincoln’s melancholy did not seem so out of form considering the turmoil of his presidency. Because of the terrible carnage, he was viewed as responding appropriately to the awful toll of the war. So his sad-looking face, his quizzical and distant glance, and his eloquent skepticism were not seen as nihilistic expressions of depression, but as the expected response of a man who was sensitive to the loss of human life.
Today America salutes him as the best president they had ever.

Winston Churchil:
‘Black Dog’ was Churchill’s name for his depression, and as is true with all metaphors, it speaks volumes. The nickname implies both familiarity and an attempt at mastery, because while that dog may sink his fangs into one’s person every now and then, he’s still, after all, only a dog, and he could be cajoled sometimes and locked up other times.
As a child he felt unloved by his parents and he is supposed to have said, “If I cannot be loved, I will find a way to be admired.”
In the 1940s that is what happened. England needed a hero. Not a shrewd, equable, balanced hero, but a prophet, a heroic visionary, a man who could dream dreams of victory when all seemed lost. Churchill was such a man; and his inspirational quality owed its dynamic force to the romantic world of fantasy in which he had his true being.
He had tied his black dog up and got on with the work of winning the war for England and today England remembers him as the best prime minister they ever had.

Princess Diana:
For years, the public believed that Diana was living a fairy tale life, married to her real life Prince Charming. However, this was far from the truth. According to Diana: The Last Word by Simone Simmons, late in her first pregnancy Diana threw herself down a staircase trying to draw attention to her pain.
She said of the incident, “I wanted Charles to put his arms around me and say he loved me, but all he ever did was give me a pat on the back.” In a 1995 interview conducted by the BBC, Diana revealed that she had suffered from post-natal depression after her first son, Prince William was born. She admitted to self-injuring due to the pressure she felt trying to adapt to her role as Princess of Wales, but said it backfired since rather than getting her the help she needed, it made people believe she was attention-seeking and unstable.
She also confessed to secret binging and purging of food to help her deal with her marriage problems, including the fact that her husband was still in love with a former girlfriend, Camilla Parker Bowles. But later she overcame her personal struggles and was about to come out as a new woman when the accident took her life away.
She will always be the people’s princess in Britain.

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