Depression is the 4th major health burden world wide. There are basically three types:
- Adjustment Disorder where depression is due to a cause as in grief or with chronic pain or other medical condition.
- Recurrent Depression where there are recurring bouts of depression without identifiable cause. Thought to be largely hereditary but the risk is compiled by the combined weighting from up to 100 genes+. Recurrent depression is more common in persons with anxiety disorders
- Bipolar Disorder where there are recurrent depressive episodes but also at least one episode of elevated mood lasting three or more days and characterised by decreased sleep, increased spending, increased risk-taking behaviour, racing thoughts.
Its important to make sure there is no underlying medical condition causing the depressive symptoms. For example- thyroid disease, iron deficiency, vitamin deficiency.
The two main forms of treatment for depression are cognitive therapy (CT) and antidepressant medication (ADM). In studies they are comparable in effectiveness. However, on treatment cessation there is a higher relapse rate for ADM than for CT suggesting CT produces a more enduring change in the underlying predisposition to depressive illness.
You might think “well why waste time on antidepressants when all they do is supress my depressive symptoms rather than cure my depression“. The catch is there is no one-size-fits-all psychotherapy. As one patient of mine put it “I understand the principle of CT but I can’t seem to apply it to my depression!”
There are bottom up and top down dysfunctions in brain systems in depression.
From the bottom up there is increased activation of the pulvinar nucleus of the thalamus and greater response in the amygdala, insula and anterior cingulate to negative stimuli.
From the top down there is a failure of dopamine reward circuits in the striatum and of executive control in the orbito-frontal and dorso-lateral prefrontal cortices.
In essence people with depression are excessively responsive to negative information and fail to experience/consider alternative positive explanations.
ADM appears to work at the level of the amygdala , decreasing reactivity over time. Since all antidepressants take at least three weeks to work it doesn’t do this be simply altering neurotransmitter levels ( which happens quite quickly) Under the influence of a neuronal growth agent, BDNF, there is a re-working of neural circuits. Interestingly, BDNF is also increased with moderate aerobic exercise-hence its benefit for depressed people. (The required exercise regime is 3 or more 35min moderate aerobic workouts per week).
CT appears to work by strengthening of executive control of prefrontal circuits.
So ideally a combined ADM and CT approach + lifestyle management is the way to go with management of depression.
Finding a suitable antidepressant regime is trial and error and many people have trials of tree or so antidepressants before an effective and tolerable one is found. Generally the Serotonergic anti-depressants, like Fluoxetine, improve a sense of misery whereas the Noradrenergic anti-depressants, like Mirtazepine and Desvenlafaxine , are helpful for lowered motivation and energy levels. Sometimes antidepressants are used in combination. Anti-depressants effectiveness can also be strengthened by adding other agents to the regime (so called augmenting agents).
TIPS FOR MANAGING DEPRESSION
The following features of depression are particularly damaging and are targets for counter-strategies:
Low mood is tiring and depleting. Logically therefore one has to build more replenishing activities into one’s day.
- light exercise
- Examples: snacks of favourite foods
Depression causes time any sense of progress to stand still. You must establish a routine and stick to it. Keep track of the day and date.
- Keep a mood diary ie: each day rate your mood 0-10 am,pm and evening You may just spot a pattern.
- Read basic good news or funny news items. Glasbergen Cartoons on the Internet are good.
Depression interferes with attention, concentration and short term memory causing you to forget or bungle simple instructions.
- Keep listsPractice mental stimulation with simple quizzes, crosswords ,jigsaws etc and observe it- try to notice new things you never had time to notice before.
- Focus on one ordinary household item a day eg a pot plant, an ant –
- (Partners) break instructions down one step at a time
Low mood often causes repeated negative memories/or ruminations-or anxiety ( “ What am I going to do if this never goes away…”)
- Every-time you have this thought –distract yourself by trying to remember as many details as you can of your favourite song or movie.
- Another strategy is to daydream an imaginary game of football as if you are playing
Depressed or anxious people try to control the world. “If everybody in the world just did what I want them to do then I things would be OK ” Not true
Its tempting to hide from the world in bed because you feel so tired and nothing is The stresses will come out in dreams anyway.The same applies to alcohol abuse- just like sleeping all day it digs the depression hole deeper.
- Leave the house for some period every day.
- Things only become fun if you do them enuf times
- Sleeping all day makes you more irritable and tired. Its better to aim for fitness
- Hiding in bed makes the world more threatening
Pathological guilt ! We have most of us grown up in 2000 yrs + of Judaic/Christian culture – “we must have done something wrong to deserve this pain“.
- Don’t get guilty and angry at your self- get angry at the depression and tell it you are going to resist its efforts to turn you into a vegetable every inch of the way!
- Depression is a disease like the glandular fever. Anyone can catch it
- Do-not worry about the big picture- shift focus to day to day.
- Setting quick accomplishable easy goals which makes life move along again. Whether the goal is simply completing a jigsaw or seeing all John Wayne’s movies –doesn’t matter.
Suicidal thoughts. Well we all have these when life is painful. In theory it’s a Impulsive suicidal gestures will most likely fail and end you up in hospital possibly crippled and worse off.
- Depression like sports injuries always goes away.
- Thinking about it is OK making plans and preparations is not. Tell someone.
- Fast way out – often doesn’t work that way though!
When one is depressed it is routine to be self-absorbed and self-centred.
- Apology is useful after losing it. Children respect adults who can admit they were wrong
- Schedule a pleasant activity with your partner once per week (eg a movie)
After recovering from depression your stress/frustration tolerance will be low
- Prioritise things
- Simplify jobs wherever possible
- Allow yourself some down time
- Reduce unnecessary stressors
- Keep up the self-nurturing activities