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The figures are going up as more and more people are feeling down. By 2020 the World Health Organisation estimates depression will be among the world’s leading causes of disability and loss of productivity. YOU Pulse investigates this debilitating condition…
By Ilse Pauw and The Health24 Team
It affects twice as many women as men but doesn’t discriminate on the grounds of race or age, social standing or intelligence. It drains your energy but can keep you awake all night. It makes you desperate for help, yet it somehow undermines the very relationships you need. It can in fact ruin your life.
Depression is not simply a bad case of the blues. It’s a common and diagnosable medical illness with physical symptoms such as low energy levels and sexual dysfunction, mental issues such as concentration difficulties and indecisiveness, and emotional responses including hopelessness and irritability.
Every year six to 10 per cent of the world’s population experience a depressive episode. And these figures are increasing. The World Health Organisation has estimated by 2020 depression will be among the world’s leading causes of disability and loss of productivity.
Despite being more prevalent this condition shouldn’t be confused with feeling down, for example, or the grief following a real loss.
“It’s perfectly normal to feel low at times,” says Health24’s cybershrink, Professor Michael Simpson. “But it shouldn’t be so severe that it interferes with your work or your personal life. And it shouldn’t last for too long.”
Grief can certainly feel like depression but it tends to improve in about six months. Also, grief isn’t relieved by medication.
“On the other hand,” Professor Simpson says, “long-lasting physical symptoms such as disturbed sleep and changes in appetite can actually indicate depression.”
Why me?
Exactly what causes this distressing mental state is not known. Research has revealed a range of possible biological, physical, social and psychological factors that could sow the seeds for its development.
One biological factor involves neurotransmitters. These chemicals in the brain control the passage of impulses between the nerve cells. When the functioning of these chemicals is disturbed – for example after taking certain medication or using recreational drugs such as Ecstasy – depression can take root or deepen.
Genes can also play a role: having a close family member who’s suffered from a depressive disorder increases your risk of developing the condition. Illnesses such as Parkinson’s or Cushing’s disease, stroke and thyroid disorders can also cause or increase depression.
On a social level specific adverse family situations and dynamics can increase your vulnerability. Divorce, for example, can trigger feelings of regret, remorse and failure.
“There are also factors like being in an ongoing unhappy relationship,” says Cape Town clinical psychologist Charl Hattingh. “Combine that with external factors and you could become depressed.”
Certain personality traits – such as pessimism and an inability to cope with stress – can lay the foundation for an emotional fall. Or, Hattingh says, “an emotional scar left by trauma at an early age can pave the way for a predisposition to depression.”
Perhaps that’s why no age or stage of life is exempt from depression. According to Dr Graham Emslie of the Department of Psychiatry at the University of Texas, an estimated two per cent of six-to 12-year-old children and eight to 14 per cent of 15- to 18-year-old adolescents suffer from depression.
The condition is often misdiagnosed in young patients because the symptoms are unusual or unexpected. Depressed children become clingy or reluctant to go to school, while teenagers might perform poorly at school, take drugs or drink excessively, become sexually promiscuous or run away from home.
Whatever the patient’s age a specific trigger – the proverbial last straw – can be identified in some. In others depression hits for no explicable reason, although these patients have usually experienced depressive episodes in the past.
“The first episode is commonly triggered by a stressful event, such as the death of a loved one,” says Professor Piet Oosthuizen, a psychiatrist at the University of Stellenbosch. “Each depressive episode reduces the threshold for the next episode, which means you need less and less stress to trigger subsequent bouts. So depression begets depression.”
Treating it right
With the proper treatment 80 per cent of depression sufferers will improve and 60 per cent will recover fully. But what is proper treatment? Ideally it’s a combination of medication and therapy, although in severe cases hospitalisation may be necessary.
Depression tends to be associated with a lack of one or more neurotransmitters. Antidepressant medication can help to correct the imbalance by enabling the smaller amount of the neurotransmitter that’s released to last longer or act more effectively.
The range of modern antidepressants is wide and most have fewer side effects than older versions, the most common being nausea and headaches during the first week and sexual side effects such as delayed orgasm and low libido. Fortunately most of these symptoms improve or disappear with time.
The most commonly used antidepressants are Selective Serotonin Reuptake Inhibitors (SSRIs). Prozac, Cipramil, Zoloft and their generics act on the neurotransmitter serotonin. They’ve earned a good reputation because they’re safer than older antidepressants when taken in overdose – and some are very effective in treating anxiety, which commonly accompanies depression.
The new drugs on the block, the Serotonin and Noradrenaline Reuptake Inhibitors (SNRIs), are earning increased popularity. Their side effects are similar to those of SSRIs, but the SNRIs are favoured when depression comes with physical symptoms such as headaches and muscular pain. They may also be more effective in preventing relapses.
However, it’s not just a matter of which drug to take but also how long you need to take it. “If it’s the patient’s first depressive episode and the antidepressant works, the patient needs to take the medication for a year,” says Professor Oosthuizen. “After a second episode it needs to be taken for two years, and lifelong after a third episode.”
A common mistake is stopping treatment prematurely or abruptly. A certain concentration of these drugs has to be reached before they become effective and this takes about a month. In the elderly it can take even longer. So stopping the treatment too soon increases your chance of a relapse or a chronic, recurring illness. Quitting abruptly can also lead to unpleasant side effects such as anxiety or dizziness. Always consult your doctor before stopping and find out how gradually you should reduce the dose.
Treating depression is often muddied by controversy and those in need of medication are put off by reports that antidepressants are prescribed too freely.
“This is a myth,” Professor Oosthuizen says. “The truth is antidepressants are not prescribed often enough. Research shows fewer than 50 per cent of people with depression are properly diagnosed and fewer than half of those are treated effectively with psychotherapy, medication or both.”
Professor Simpson echoes this point but adds antidepressants are not necessarily the best path for all patients. “Many experts wouldn’t recommend medication in every case, especially from the start,” he says. “And loads of research shows cognitive behavioural therapy – which focuses on changing maladaptive thoughts, feelings and behaviour – can be as effective as antidepressants and have lasting benefits.”
Hattingh agrees that medication is sometimes nothing more than a Band Aid – a temporary cover for a chronically infected wound.
“Even if a person feels better on an antidepressant, emotional problems can return unless factors such as an unhappy relationship are addressed,” he explains. “That’s a possible disadvantage of medicating depression: the patient doesn’t feel it necessary to address the underlying causes.”
On the other hand therapy helps the patient to face facts and identify the emotional causes of the depression. “You learn to understand where the tendency to react to adversity with depression comes from,” Hattingh says. “Then, in a safe therapeutic environment, you can learn new ways to deal with trauma and loss.”
Clearly, if a patient’s day-to-day functioning is deeply affected, medication has to be considered. In an ideal situation antidepressants help a struggling patient to manage the symptoms while therapy gets to the root of the problem.
During very severe depression or if a patient doesn’t respond to medication, electroconvulsive therapy (ECT) – known as shock therapy – may be considered. This scary-sounding treatment delivers brief, mild electrical stimulation to the brain, causing a small seizure which helps to relieve symptoms. After ECT the brain displays similar changes to those seen after antidepressant medication. But the improvement is faster with ECT.
Today’s shock therapy is nothing like that used a few decades ago. It’s neither painful nor dangerous but some people do report memory loss when the treatments are close together or when ECT is applied to both sides of the brain.
All in all the treatment options and combinations are decidedly complex. But research suggests the longer depression is left untreated the harder it may be to treat. So whatever the plan of action, experts agree the key to success is seeking help as soon as possible.
The three most common mood disorders
1 Major Depressive Disorder (MDD)
This type of disorder is characterised by a depressed mood and/or a loss of interest and pleasure in almost all activities for at least two weeks. Several other symptoms can also be present, including sleep disturbances, appetite changes, low energy levels, sexual problems and concentration difficulties. These symptoms interfere with the patient’s usual behaviour and ability to function.
2 Dysthymia
This is a tricky condition to diagnose because although many MDD symptoms are present they tend to be less severe. Their interference with the patient’s usual behaviour and functioning is milder. But the symptoms are chronic and may continue for years. Sufferers seldom feel truly happy or really enjoy life and in the long term many don’t reach their full potential. That’s why dysthymia can be severely disabling and has long-lasting consequences.
3 Bipolar Disorder
Formerly known as manic depression (a term that’s no longer used because there are many variations), bipolar disorder generally has poorer long-term improvement prospects than MDD. It tends to be chronic with episodes of depression alternating with episodes of mania or euphoria. The mood switches are usually gradual but can also be fairly sudden and dramatic.
Are you depressed?
Identifying depression requires an understanding of the specific signs. You might be depressed if five or more of the following symptoms have been present for two continuous weeks and indicate a change from your usual behaviour and mood. At least one of the first two symptoms must be present.
- Depressed mood most of the day and nearly every day. This is either recognised by you, for example feeling sad and empty, or observed by others, for example often being tearful. In children and teenagers irritability is a symptom.
- Markedly reduced interest or pleasure in all or almost all activities for most of the day and nearly every day, as recognised by yourself or others.
- Significant weight loss or gain when not intended or a major decrease or increase in your daily appetite. In children this manifests as a failure to gain weight normally.
- Insomnia or excessive sleeping.
- Restlessness or slower movements noticeable to others.
- Fatigue or loss of energy nearly every day.
- Feeling worthless or inappropriately or excessively guilty nearly every day.
- Difficulty concentrating or thinking clearly, noticed by you or others.
- Recurring thoughts of death and/or suicide with or without a specific plan for acting on these thoughts.
Who do you turn to?
The South African Depression and Anxiety Group is open from 8 am to 8 pm every day of the week and has trained counsellors on hand to listen, talk and refer. Call them toll-free on their helpline at 0800-567-567 or SMS 31393.
