What you should know about
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 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.
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
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,”
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.
“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
• 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.
“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.
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.”
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
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.
“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.
“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.
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.
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.
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
• 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.
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.
• Recent research shows that elderly women who have a vitamin B-12
deficiency are twice as likely to be severely depressed as those without
• 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
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
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
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
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
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.
Famous people who beat depression
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
Today America salutes him as the best president they had ever.
‘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.
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.