Depression

What is Depression?

Depression is a common experience. We have all felt 'depressed' about a friend's cold shoulder, misunderstandings in our marriage, tussles with teenage children – sometimes we feel 'down' for no reason at all.

However, depression can become an illness when:

  • The mood state is severe
  • It lasts for 2 weeks or more and
  • It interferes with our ability to function at home or at work.

Signs of a depression include:

  • Lowered self-esteem (or self-worth)
  • Change in sleep patterns, that is, insomnia or broken sleep
  • Changes in appetite or weight
  • Less ability to control emotions such as pessimism, anger, guilt, irritability and anxiety
  • Varying emotions throughout the day, for example, feeling worse in the morning and better as the day progresses
  • Reduced capacity to experience pleasure: you can't enjoy what's happening now, nor look forward to anything with pleasure. Hobbies and interests drop off
  • Reduced pain tolerance: you are less able to tolerate aches and pains and may have a host of new ailments
  • Changed sex drive: absent or reduced
  • Poor concentration and memory: some people are so impaired that they think that they are becoming demented
  • Reduced motivation: it doesn't seem worth the effort to do anything, things seem meaningless
  • Lowered energy levels.

If you have such feelings and they persist for most of the day for more days than not over a two week period, and they interfere with your ability to manage at home and at work, then you might benefit from getting an assessment by a skilled professional.

Having one or other of these features, by themselves, is unlikely to indicate depression, however there could be other causes which may warrant medical assessment.

If you are feeling suicidal it is very important to seek immediate help, preferably by a mental health practitioner. See Getting Help and Emergency Help.

Please note that the information in this section (or anywhere on this site) is not intended as a substitute for professional medical advice, so please see a qualified health provider if you have any health concerns.

Causes

While researchers often talk about 'finding the cause' of some disease or disorder this often obscures the fact that only part of the story is known. Some causes are pretty straightforward. We know that a broken leg is usually the result of some kind of pressure or strain being applied. Moreover, if you have a broken leg you typically know when it happened (leg was fine yesterday, today it is broken) and how it happened (this morning you went skiing).

Things are not so simple with depression. We have good ideas about what some of the 'pressures or strains' that result in depression are – but they are not all agreed upon and there might be others.

For any one person there could be many 'pressures' in their life. It's often unclear when the depression started, much of the time its effect is gradual.

We can see another complication by going back to the broken leg example. Some people suffer from osteoporosis which makes their bones more fragile (more vulnerable). If you only had a minor accident when you went skiing, your osteoporosis was probably as much the cause of your broken leg, since it made your leg more vulnerable to the effects of pressure. If you have a major accident, however, the leg will probably break, osteoporosis or not.

In other words, the causes of depression are some mixture of 'pressure' (mild to severe) combined with a vulnerability to depression (as a sort of 'psychological osteoporosis') which too can range from mild to severe.

Also, for each 'sub-type' of depression, differing 'mixtures of causes' have differential relevance. So, for psychotic or melancholic depression physical and biological factors are generally more relevant. By contrast, for non-melancholic depression, the role of personality (the presence of osteoporosis) and life-event stressors (having an accident) are generally far more relevant.

What it's Like

The experience of depression may be very different from one person to the next, depending on the type of depression the person has, and their personality and coping styles. Many of the signs of depression would be clearly evident in a person who has depression. For others it may not be, as depression can often lead the person to withdraw from social contact or to hide their real feelings from those around them.

Generally speaking, someone who is depressed would:

  • have a low mood
  • be pessimistic
  • have lowered self-esteem
  • feel hopeless and helpless.

They may want to walk away from things, for example, their job or a difficult marriage.

In some types of depression, individuals may:

  • physically slow down (walk and talk more slowly OR become agitated and unable to sit still)
  • find it difficult to get up in the morning
  • find it difficult to initiate even basic activities like showering or dressing.

People with non-melancholic depression can sometimes be cheered up on occasions, for example by a pleasant event, or with support from a friend.

Personality styles also play a part in the effect of depression. Some people will fail to see their strengths and focus on their failings, believing they are less competent than they really are, and sink lower into depression, while others may become angry and irritable with those around them.

Behaviour may also be affected by an individual's coping style. For instance, some people would indulge more than usual in junk food or in material possessions, while others may turn to friends for support or seek professional help. A desire to escape the despair may cause some individuals to use drugs and/or alcohol, or even to have thoughts of suicide.

Talk of suicide should be taken seriously and treatment should be sought immediately, preferably from a mental health professional or other appropriate person. (See Getting Help and Emergency Help).

How to tell if someone else has depression

Just because we know someone well does not mean we will always notice when they have changed. Big changes or sudden ones are likely to be noticed, but if someone changes slowly it is easy to miss the change. Also, even people we know well (including those close to us) will not always reveal all their thoughts and feelings. Since we cannot expect to always realise that someone is depressed, we ought not feel guilty that we 'did not know'.

The sensible approach is to be aware that depression is not uncommon and to understand the common signs and symptoms. Then, if you are worried that someone is depressed, the best thing to do is to talk to them about it and/or suggest that they go to see a mental health professional.

Treatments

A large number of different treatments are available for depression. New treatments (particularly medications) appear regularly. Continuing research means that the evidence for how well a treatment works is always changing too. We have chosen to give only a brief summary of treatments and instead direct you to other sites which provide more comprehensive details.

Key points about treatments for depression

  • We believe that different types of depression respond best to different sorts of treatments (see below)
  • It's important that a thorough and thoughtful assessment be carried out before any treatment is prescribed
  • Treatments for depression include physical and psychological interventions
  • Depression can sometimes go away of its own accord but, left untreated, it may last for many months. Allow yourself to seek help
  • Depending on the nature of your depression, self-help and alternate therapies can also be helpful, either alone or in conjunction with physical and psychological treatments.

Different types of depression need to be treated differently

At the Institute we believe there are different types of depression, falling into the following three principal classes:

  1. "Melancholic depression
  2. Non-melancholic depression
  3. Psychotic depression.

Those types of depression that are more biological in their origins (melancholic depression and psychotic depression ) are more likely to need physical treatments and less likely to be resolved with psychological treatments alone.

We believe non-melancholic depression can be treated equally effectively with physical treatments (antidepressants) or with psychological treatments.

Physical Treatments

The main physical treatments for depression comprise:

New treatments being trialled at the Black Dog Institute include:

Drug Treatments

There are three groups of drugs most likely to be used for depression:

Antidepressants

  • There is a large number of antidepressants – they have a role in many types of depression and vary in their effectiveness across the more biological depressive conditions
  • Selective Serotonin Reuptake Inhibitors (SSRIs), Tricyclics (TCAs) and Irreversible Monoamine Oxidase Inhibitors (MAOIs) are three common classes of antidepressants. They each work in different ways and have different applications
  • At the Institute we believe that they are not, however, equally effective and that it is necessary to find the right antidepressant for each person
  • If the first antidepressant does not work, it is sensible to move to a different kind of antidepressant. For the biological depressive disorders, more broad action antidepressants are usually more effective
  • A well-informed health provider should be able to use their assessment of the type of depression, its likely causes and their understanding of the person to identify the medication most likely to benefit
  • Finally, being able to decide not to use medication is important too.

Tranquillisers

  • These medications are usually called 'minor' or 'major' tranquillisers
  • Minor tranquillisers (typically benzodiazepines) are not helpful in depression; they are addictive and can make the depression worse
  • Major tranquillisers are very useful in people with a psychotic depression and in melancholic depression where the person is not being completely helped by other medications.

'Anti-manic' drugs or 'mood stabilisers'

  • These drugs are of great importance in bipolar disorder.
  • Their use in treating mania makes them 'anti-manic', while their ability to reduce the severity and frequency of mood swings makes them 'mood stabilisers'.
  • Lithium, valproate and carbamazepine are the most common, while the use of lamotrigine is increasing.

It is important to remember that the anti-depressants and mood stabilisers are often necessary both to treat the depression that is occurring now, and to make a relapse in the future less likely. So people sometimes need to continue taking medication for some time after they are feeling better.

Electroconvulsive therapy (ECT)

Because of its controversial past many people feel the need to think carefully before having ECT or allowing it to be given to relatives.

Clinicians at the Institute firmly believe that ECT has a small but important role in treatment, particularly in cases of

  • Psychotic depression
  • Severe melancholia where there is a high risk of suicide or the patient is too ill to eat, drink or take medications
  • Life-threatening mania
  • Severe post-natal depression.

While there are some short-term side-effects, ECT is relatively safe and, because an anaesthetic is used, not too unpleasant.

Psychological Treatments

There are a wide range of psychological treatments for depression.

Some of the main ones are:

Psychological treatments provide either an alternative to medication or work alongside medication. As always, a thorough assessment of the person is needed in order to decide on the best set of approaches.

Cognitive Behaviour Therapy (CBT)

People suffering from depression – particularly 'non-melancholic depression' – will often have an ongoing negative view about themselves and the world around them. This negative way of thinking is often not confined to depression, but is an ongoing part of how the person thinks about life. Many or all of their experiences are distorted through a negative filter and their thinking patterns become so entrenched that they don't even notice the errors of judgement caused by thinking irrationally.

Cognitive behaviour therapy aims to show people how their thinking affects their mood and to teach them to think in a less negative way about life and themselves. It is based on the understanding that thinking negatively is a habit, and, like any other bad habit, can be broken.

CBT is conducted by trained therapists either in one-on-one therapy sessions or in small groups. People are trained to look logically at the evidence for their negative thoughts, and to adjust the way they view the world around them. The therapist will provide 'homework' for between sessions. Between 6-10 sessions can be required but the number will vary from person to person. More recently, a number of online programs have been developed to deliver CBT to people in their own homes.

CBT can be very beneficial for some individuals who have depression but there will be others for whom it is irrelevant.

See also Consulting a psychologist

Interpersonal Therapy (IPT)

The causes of depression, or our vulnerabilities to developing depression, can often be traced to aspects of social functioning (work, relationships, social roles) and personality.

Therefore, the underlying assumption with interpersonal therapy is that depression and interpersonal problems are interrelated.

The goal of interpersonal therapy is to help a person understand how these factors are operating in their current life situation to lead them to become depressed and put them at risk for future depression.

Therapy occurs in three main phases:

  • an evaluation of the patient's history
  • an exploration of the patient's interpersonal problem areas and the development of a treatment contract
  • recognition and consolidation by the patient of what has been learnt and developing ways of identifying and countering depressive symptoms in the future.

Usually 12-16 sessions of IPT will be required.

Mindfulness-Based Cognitive Therapy

Mindfulness-based Cognitive Therapy is a relatively new form of treatment for depression. This approach was developed by Segal, Williams and Teasdale (adapted from the work of Jon Kabat-Zin) in order to prevent relapse for those who had previously experienced an episode of depression.

Mindfulness is a form of self-awareness training that has been taken from mindfulness meditation. Mindfulness is about being aware of what is happening in the present on a moment by moment basis, while not making judgements about whether we like or don't like what we find.

Generally Mindfulness-based Cognitive Therapy is undertaken in an 8-week group program format, however often psychologists use these techniques in one-on-one therapy sessions depending on their training and experience.

Other mindfulness-based approaches have also been developed that may be used for depression (eg. MiCBT) and therapies such as Dialectical Behaviour Therapy and Acceptance and Commitment Therapy also use components of mindfulness in their approach.

See our handout for tips and techniques on how to use mindfulness in everyday life.

Positive Psychology

Positive Psychology is a new area of psychology that focuses on the conditions that contribute to flourishing or optimal functioning.

"Positive Psychology is founded on the belief that people want more than an end to suffering. People want to lead meaningful and fulfilling lives, to cultivate what is best within themselves, to enhance their experiences of love, work, and play. We have the opportunity to create a science and a profession that not only heals psychological damage but also builds strengths to enable people to achieve the best things in life." Professor Martin Seligman, founder of Positive Psychology. Positive Psychology researchers have identified many everyday activities that improve wellbeing. These include; keeping a gratitude diary, performing small acts of kindness, learning to savour enjoyable moments and varying pleasant experiences to avoid routine.

See our fact sheets: 'Positive Psychology' and 'Happiness'.

Psychotherapies

Psychotherapy is an extended treatment (months to years) in which a relationship is built up between the therapist and the patient. The relationship is then used to explore aspects of a person's past in great depth and to show how these have led to the current depression. Understanding this link between past and present – insight – is thought to resolve the depression and to make a person less vulnerable to becoming depressed again.

See Consulting a psychotherapist

Counselling

Counselling encompasses a broad set of approaches and goals that are essentially aimed at helping an individual with problem solving – solving long-standing problems in the family or at work; or solving sudden major problems (crisis counselling).

Read more about counselling

Narrative Therapy

Narrative Therapy is a form of counselling based on understanding the 'stories' that people use to describe their lives. The therapist listens to how people describe their problems as stories and helps the person to consider how the stories may restrict them from overcoming their present difficulties. It sees problems as being separate from people and assists individuals to recognise the range of skills, beliefs and abilities that they already have (but may not recognise) and that they can apply to problems in their lives.

Narrative Therapy differs from many therapies in that it puts a major emphasis on identifying people's strengths, particularly as they have mastered situations in the past and therefore seeks to build resilience rather than focus on their shortcomings.

Q & As

1. What are the signs of depression?

The following are a list of the features that may be experienced by someone with depression.

  • Lowered self-esteem
  • Change in sleep patterns
  • Change in mood control
  • Varying emotions throughout the day
  • Change in appetite and weight
  • Reduced ability to enjoy things
  • Reduced ability to tolerate pain
  • Reduced sex drive
  • Suicidal thoughts
  • Impaired concentration and memory
  • Loss of motivation and drive
  • Increase in fatigue
  • Change in movement
  • Being out of touch with reality.

Note that, having one or other of these features, by themselves, is unlikely to indicate that someone is clinically depressed. Also, having these features for only a short period (of less than two weeks) is unlikely to indicate clinical depression. It's also important to know that many of the above features could be caused by or related to other things, such as a physical illness, the effects of medications, or stress. Help in coming to such decisions should be assisted by a proper assessment by a trained professional.

2. How depressed should I be before I seek help?

Everybody feels down or sad at times. But it's important to be able to recognise when depression has become more than a temporary thing, and when to seek help. As a general rule of thumb, if your feelings of depression persist for most of every day for two weeks or longer, and interfere with your ability to manage at home and at work or school, then a depression of such intensity and duration may require treatment, and should certainly benefit from assessment by a skilled professional.

3. What should I do if I'm feeling (or someone close to me is feeling) suicidal?

  • See the list of emergency contact numbers (and add the numbers of your General Practitioner and your local Community Mental Health Service) and keep a copy handy somewhere. Don't hesitate to call one of them if in need of help
  • Recognise that having suicidal thoughts is one of the features of depression, and seek help, either from your General Practitioner or another mental health professional such as a psychologist or a counsellor. Make sure you tell them you have been having suicidal thoughts
  • If you have already received treatment for depression, and you are having suicidal thoughts, contact the person who has been giving you the treatment, or a close friend who you trust, and tell them you are feeling suicidal
  • If someone close to you is suicidal or unsafe, talk to them about it and encourage them to seek help. Help the person to develop an action plan, involving him or her and trusted close friends or family members, to keep him or her safe in times of emergency
  • Take away risks (e.g. remove guns or other dangerous weapons and hold the keys of the car if the depressed person is angry, out of control and wanting to drive off into the night).

4. Am I always going to feel like this?

This is a common fear. It's important to know that it will pass. Depression can be successfully treated and that you will feel better in time and with the right treatment.

5. How long does depression last

Sometimes depression goes away of its own accord, but, depending on the nature and type of the depression, it may take many months and possibly considerable suffering and disruption if left untreated. Allow yourself to seek help in the same way you might if you had a physical illness.

6. How is depression treated?

There are a large number of different treatments for depression. At the Black Dog Institute we believe that different types of depression respond best to different treatments and it is therefore important that a thorough and thoughtful assessment be carried out before any treatment is prescribed.

Treatments can fall into the following categories:

Physical treatments, comprising :

  • drug treatments, of which there are three main groups: antidepressants, tranquillisers, and mood stabilizers.
  • electroconvulsive therapy (ECT) – a physical therapy that may be relevant in a minority of cases of psychotic depression, severe melancholia or life-threatening mania.
  • transcranial magnetic stimulation- a treatment that is still under development, but which involves holding a coil near to a patient's head and creating a magnetic field to stimulate relevant parts of the brain.

Psychological treatments, the most common ones being:

  • Cognitive Behaviour Therapy – a form of therapy that aims to show people how their thinking affects their mood and to teach them to think in a less negative (and more 'realistic') way about life and themselves.
  • Interpersonal Therapy – a therapy that aims to help people understand how social functioning (work, relationships and social roles) and personality operate in their lives to affect their mood.
  • Psychotherapy – an extended treatment aimed at exploring aspects of the person's past in great depth to identify links to the current depression.
  • Counselling- a broad set of approaches and goals that provide problem solving and learning skills to cope with difficult life circumstances.

Find out more about treatments for depression.

7. Where can I get help for depression?

A good first place to start in getting help is to visit your local General Practitioner. Let him or her know if you think you might have depression. Your General Practitioner will either conduct an assessment of you to find out whether you have depression, or refer you to someone else, such as a psychiatrist or a psychologist.

Depending on the nature of your depression, your General Practitioner may recommend some psychological intervention, such as cognitive behaviour therapy or interpersonal therapy, and might prescribe antidepressant medication to relieve some of the symptoms of depression.

Because depression is a common experience these days, many General Practitioners are used to dealing with depression and other mental health problems. Some General Practitioners take a special interest in mental health issues and undergo additional training in the area. If you don't feel comfortable talking to your own doctor, find another one with whom you do feel comfortable. It is important that you feel comfortable talking about how you are feeling with your doctor so they have as much information to help you as possible.

If you are having trouble tracking down such a General Practitioner, you could telephone general practices in your area to find out whether any doctors in that practice have a particularly strong interest in mental health and, if so, whether they are taking on new patients. (Ask to speak to the practice manager.)

Psychologists, psychiatrists and counsellors are other professionals trained to provide help for depression and mood disorders. You will need a referral from your doctor to see a psychiatrist (and this will either eliminate or reduce costs).

Social workers, occupational therapists and registered nurses are also trained in mental health.

Find out more about consulting a professional.

8. How should I behave with someone who is depressed?

Someone with a depressive illness is like anyone with an illness – they require our care. You can provide better care if you are able to:

  • Understand something about the illness
  • Understand what the treatment is, why it is being given, and how long the person is expected to take to recover.

An important part of caring is to help the treatment process:

  • If medication is prescribed encourage the person to persist with treatment (especially when there are side effects)
  • Counselling or psychotherapy often results in the depressed person 'thinking over' their life and relationships. While this can be difficult for all concerned, you should not try and steer the person away from these issues.
  • A resolving depression sometimes sees strong emotions released which may be hard on the carer. The first step in dealing with these fairly is to sort out which emotions really refer to the carer and which refer to other people or to the person themselves.
  • Treatment has a positive time as well – when the person starts to re-engage with the good things in life and carers can have their needs met as well.

Don't forget that as a carer you too are likely to be under stress. Depression and hopelessness have a way of affecting the people around them. Therapy can release difficult thoughts and emotions in carers too. So part of caring is to care for your own self – preventing physical run-down and dealing with the thoughts and emotions within yourself.

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