Sandhya (name changed) is a 22-year-old woman teaching at a school. She was known to be a warm, extroverted person and an efficient worker. Around this time her romantic relationship terminated. She did not disclose this to anyone. However, her colleagues, friends and family noticed some changes in her behavior. She appeared to be very slow and lethargic, took many leaves from school, did not indulge in her favorite pastimes and interacted little even with her best friend.
The school authorities started rebuking her for being careless. Sandhya’s friends and family tried to talk things out but when she did not cooperate they felt rejected and angry.
Consequently, they distanced themselves and let her be alone. As days passed by Sandhya retreated into a cocoon. She felt that she was absolutely alone in the world and that her life would always be fraught with darkness and despair. She believed that nothing could change her condition and that it was better to die. One of her friends took her to a mental health professional who diagnosed her as suffering from depression. She was given counseling along with anti-depressant medication and she improved. Had this friend not taken the initiative Sandhya might have committed suicide.
What is depression?
Depression is a common psychological disorder that affects a large percentage of Indian population. Though the disorder is easily treatable but ironically it is not recognized by the patient, their close ones and the general medical practitioner at an early stage. Depression is characterized by:
• Persistent low mood, the person feels sad and unhappy most of the time. They feel that they are worthless human beings and become blind to their capabilities, achievements and resources. The patients indulge in harsh self-devaluation and feel that they are not worthy of love from close ones.
• An inner feeling of diminished energy, the individual experiences fatigue even after doing tasks that require minimal effort and therefore indulges in little day-to-day activity.
• A loss of interest and enjoyment in life, the person does not find pleasure in social, interpersonal and professional interactions and finds hardly any joy in the activities and hobbies that they liked.
• A sense of intense hopelessness and helplessness engulfs their mind. They think that the present and future are full of despair and nothing in the world can change this. The patients may feel abandoned by their close ones. As a result they may feel suicidal and wish to end their lives.
• A depressed person usually does not disclose these feelings to their close ones.
• Relationships are in a constant flux as the depressed person may cling to or withdraw from the close ones.
• Family members and friends may notice some marked changes in the person’s behavior such as: diminishing social contact, decreased attention and concentration, poor self-esteem and low self-confidence, disturbances in memory, poor sleep, reduced energy and slowness, restlessness and irritability, reduced food intake, loss of body weight and lack of interest in sex.
Symptoms of depression develop over days to weeks.
While some people have a single depressive episode after which they become more or less normal, around 50% suffer from a second episode after recovery. It is also important to note that according to the severity of depression there would be differences in the behavior from one individual to another. In some instances there can be a complete breakdown of social and occupational functioning, poor hygiene and bizarre behaviour.
A depressive episode can be categorized as mild, moderate or severe depending upon the intensity of symptoms. For a depressive episode to be diagnosed as mild, the symptoms should be present for a period of at least two weeks, the person feels depressed but at the same time is able to continue day-to-day living. A patient suffering from moderate depression will have relatively severe symptoms and it will be extremely difficult for them to go about their daily activities.
Further, in a severe episode of depression the distress takes a toll on the mind of the individual and there is a disruption of functioning. Also, in some cases, the severe depressive episode may be accompanied by psychotic features where the individual experiences delusions and hallucinations.
This condition needs to be diagnosed correctly as quite a few confuse it with Schizophrenia. Apart from these mild, moderate and severe categories, a person with depressive symptoms may also be diagnosed as suffering from dysthymia which is a chronic state of low mood that starts in adult life and spans for several years.
• People tend to dismiss depression as carelessness, laziness, passivity or fakeness. It is important to recognize that the depressed person is neither faking nor being careless or lazy; he or she is suffering intensely at each and every moment. If it was entirely up to their will, they would not want to be in that state for a fraction of a second. Blaming the depressed person for being careless or trying to fake is likely to make them feel even more hopeless, helpless and rejected.
• Depression is viewed by many people as an exaggerated version of normal sadness and grief. This is not true as unlike normal sadness and grief depression is steady and affects thought processes, behavior, immune system, peripheral nervous system, daily functioning, appetite, personal care and relationships.
There are many factors that may predispose a person towards depression:
• Faulty Thinking Patterns: The way we think influences the way we feel. Depressed people are flooded with negative thoughts and these lead to low mood and the gamut of other depressive symptoms. Depressed people think negatively about themselves (I’m useless), the surrounding world (no one cares for me) and the future (life is no good because these things will never change). Depressed person tends to focus exclusively on negative experiences and totally ignores the positive ones.
• Genetics: Genetic factors may predispose people towards depression as research studies have indicated that monozygotic co-twins of a depressed patient are more likely than dizygotic co-twins to become depressed.
• Neurobiological Factors: Abnormalities in monoamine neurotransmitter system especially serotonin, noradrenaline and dopamine seem to contribute to depression.
• Stressful Life Events: Stressful life events such as physical illness, death of a close one, trouble in a relationship, loss of job and decline in career precipitate depression.
• Difficulties in experiencing and expressing anger: People who become depressed have difficulty in experiencing and expressing anger in close interpersonal relationships. The depressed person is actually angry with people close to them but disavows this and turns all the anger and hatred on themselves. Depression is in a way anger turned inward.
• Childhood separation: Many depressed patients have experienced real or imagined separation from an important attachment figure in their childhood. They blame themselves for the separation thinking that it was primarily their inner badness that drove other people away. These children suffer from feelings of loneliness and insecurity and consequently have a high need to be loved and accepted by others. When this does not happen they become depressed.
Tests and Diagnosis
Currently, there are no laboratory tests for diagnosing depression. The diagnosis of depression is made by a qualified mental health professional on the basis of reported symptoms, detailed case history taking, observing the patient and mental status examination. If the information gathered from these sources meet the criteria outlined in ICD-10 (International Classification of Diseases, WHO) or DSM-IV-TR (Diagnostic and Statistical Manual of Mental Disorders, American Psychiatric Association) the diagnosis of depression is made.
Other medical conditions such as diabetes, thyroid malfunction, multiple sclerosis, head injury, AIDS, hepatitis and Parkinson’s disease may cause symptoms resembling depression and these need to be ruled out. Addiction to psychoactive substances such as alcohol and amphetamines may also lead to depression-like symptoms.
Psychological tests and psychiatric rating scales can also be used for screening purposes but cannot replace the validity of a diagnosis made by a mental health professional. The most commonly used is Beck Depression Inventory (BDI) which is a multiple choice self-report inventory. For each item, the patient is told to pick up one statement that best describes their current state. Based on the total score the individual is classified as suffering from mild, moderate or severe depression.
People close to the patient must acknowledge their distress and not criticize or belittle them. The approach should be supportive and reassuring. It is important to be vigilant if the patient has expressed suicidal ideation directly or indirectly.
There is no standard package of treatment for depression. There are many treatments available. Each patient needs to be evaluated carefully and based on this a treatment plan should be devised. A careful assessment of severity of the condition must be made along with the risk of suicide. The major goal of the treatment is to uplift the mood and improve quality of life.
Psychotherapy and counseling are extremely helpful in alleviating depression. There are several types of psychotherapies that can be given to depressed patients including supportive therapy, cognitive-behavior therapy, behavior therapy and psychoanalytic therapy. Supportive therapy and problem solving are used when depression is due to imperious current life difficulties. The patient is educated about the illness and reassured and they are encouraged to express their views in an atmosphere of trust and empathy.
The problems that they are facing currently are identified and the best possible alternative to deal with them is chosen. A plan is formulated wherein the goal is broken down into smaller attainable targets. This therapy is helpful because the patient’s ability to think rationally is affected in depression and they are overwhelmed by negative emotions. Supportive therapy can be given by clinical psychologists, psychiatrists, social workers and trained general practitioners. It is most suitable for patients having mild to moderate depression.
Cognitive behavior therapy (CBT) and antidepressant medication are the most effective treatments for depression. Though antidepressant medication is very effective in quickly alleviating symptoms of depression, CBT prevents the patient from becoming depressed again after they have recovered. A combination of both CBT and antidepressant medication works well even for the severely depressed patients. It enables the patients to change their faulty ways of thinking that lead to depression. CBT targets faulty thinking patterns, hopelessness, negative views and helplessness. It is frequently used and a majority of qualified clinical psychologists in India are trained in it.
Antidepressant medications such as tricyclics, SSRI’s and monoamine oxidase inhibitors are very effective in treating symptoms of depression and are generally combined with psychological treatment. A thorough consultation with a psychiatrist must be made before starting antidepressant medication. Any attempt at self-medication must be avoided as these medicines have side effects and need constant monitoring.
Commonly reported side-effects are tremors, constipation, sedation, dizziness, blurred vision, weight gain, sleep disturbances, anxiety and cardiac arrhythmias. Some antidepressants can prove fatal if taken in overdose. Keeping this in mind, the psychiatrist takes a thorough medical and psychiatric history of the patient. Antidepressant medication is usually started with a low dose that is gradually increased to give an optimum therapeutic effect.
Behaviour Therapy aims at altering the patient’s behaviour with a hope that it will consequently change the thought patterns and uplift mood. The techniques used are activity scheduling, self-control therapy, social skills training and problem solving.
Psychoanalytic Therapy aims at resolving the unconscious conflicts that date back to the patient’s childhood and are responsible for the current symptoms of depression. Though the process of therapy takes time, psychoanalytically-oriented work aims at a deep personality change thereby improving overall quality of life and preventing relapse. The reactions to separation are explored and interpreted to the patient in a nonjudgmental and emotionally constant atmosphere. This therapy gives the patients strength to be able to work with their past, present and future experiences of separation from loved ones. The patient should enter into such a therapy only if they are willing to make a long-term commitment.
Electroconvulsive Therapy (ECT) though once a popular form of treatment is used rarely. It becomes a treatment of choice for patients who have severe depression along with psychosis or high suicide risk and do not respond to antidepressant medication and psychotherapy.
Along with this these main treatments several adjunct alternative methods are available to alleviate the symptoms of depression and improve the overall quality of life: yoga and other forms of physical exercise, ayurveda, homeopathy, hypnotherapy, acupuncture and following a proper diet. A majority of these methods need to be subjected to rigorous research to assess their efficacy.
Therefore these treatments cannot replace medical care and should ideally be used in combination with psychotherapy and antidepressant medication when the patient is in a depressed state.
Hypnotherapy puts the patient in an altered state of consciousness and then through suggestions or age-regression tries to work through the lack of intimacy and feeling of being unloved. Some yogasanas especially simhasana (lion pose), matsyasana (fish pose), pranayama (breathing exercise), balasana (child pose) and suryanamaskar (sun salutation) have been reported to be helpful in depression. Ayurveda views depression as due to an imbalance of kapha, vata and pita and tries to cure it through herbs, diets and exercises.
Specialists proficient in acupuncture understand depression as stemming from blockages in flow of energy in the body and insert thin needles in special body points to remove these blockages. Recommended diet for depression includes reducing the intake of sugar and caffeine and cutting down on the processed food; consuming fresh green vegetables, fresh fruits and sprouts.
Do not Delay Treatment
In case you or your close one is depressed, do not delay seeking help. It is not normal sadness that would vanish on its own but is likely to become more severe and debilitating without treatment.