Mental Health Care

For people with milder form of depression, the following measures may help lift their low spirits:

Share your feelings. Be it a positive achievement or a set back­share it with people whom you love. In no case should you mull over negative thoughts or difficulties all by yourself. Discuss it out with your spouse, family member or a trusted friend. They can offer you support, guidance and perspective.

Spend time with other people. A sound social support group is the best tonic for the mind. Humans need to be with others, to belong, and to win approval. Spending time with others can shore up your low spirits.

Think positive. The ancient Indian philosophies as well as modern thinking assert that all our thoughts become reality. If we think negative thoughts, we are led to helplessness and hopelessness and ultimately we become victims of depression. On the other hand, if we are positive and optimistic in our approach, we protect our minds and bodies from harm, and help ourselves to live a longer, healthier and happier life.

Give time to activities of your interest. Engage in activities that have interested you in the past, particularly activities that you have enjoyed. Spend time on music, reading, watching movies, theatre, art exhibitions, picnics, visiting museums, rowing, playing cards, chess, carom or anything that you like.

Take regular exercise. Regular moderate exercise, like 30-45 minutes of brisk walk, workout or sport may lend much to lift your mood. It relieves you of stress and strain, and leaves you fresh, alert and rejuvenated.

Get adequate rest. Rest and sleep are the biggest balm for the body and the mind. Overwork, too much stress and anxiety do not help anybody.

Set realistic goals. Don’t undertake too much at one time. If you have large tasks ahead, break them into smaller ones. Set goals you can accomplish.

Help others to help yourself.Look out for any opportunity to be of help to someone less fortunate. The benefits are immense. Your good deed for the day fulfils an inner human urge. Every religion and humanitarian philosophy teaches you that, and the goodness bounces back with more of the same. Researchers have found that it tones up the mind, the immune system, and physical health.

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Until a few years ago, researchers believed that depression could be of two kinds: endogenous, caused by inexplicable sense of gloom; and exogenous, caused by reverses in life. That theory is no longer accepted. The current consensus is that only those people who suffer from certain biological and psychological vulnerabilities are prone to depression. Stressful life events can act as precipitating factors only. This theory explains why some people become depressed even when things are going well with them, and why others take even the most adverse circumstance in their stride and remain unaffected by it.

Biological factors

Functional imaging studies have shown that certain chemicals in the brain which act as transmitters in the brain circuit may play an important role in regulating human mood and emotions. The most significant of these are norepinephrine and serotonin.

The norepinephrine link. There is now considerable experimental evidence that a deficiency of norepinephrine in certain brain circuits leads to depression, while its overabundance generates mania. A whole, intricate mechanism has been discovered explaining how it works. The circuits that feel either paucity or abundance of norepinephrine originate in the brain stem, primarily in a region called the pigmented locus coetuleus. These circuits extend to many areas of the brain, including the limbic system, which play a significant part in regulating emotions.

Serotonin connections. Serotonin has taken the centre stage in research on the causative factors of depression, ever since the newer antidepressants that change serotonin levels have met with good therapeutic success. The view is that a deficiency of serotonin at the serotonin-using synaptic junctions in the brain circuit can upset the mood and emotions by promoting, or permitting, a fall in norepinephrine levels. The anatomical basis to this finding has also been outlined.

There may also be other mechanisms at work. Serotonin depletion might affect many brain regions that participate in depressive symptoms-including the amygdala (an area involved in emotions), the hypothalamus (involved in appetite, libido and sleep) and cortical areas that participate in cognition and other higher processes.

The most clinching evidence to the serotonin theory comes from these medications, called the selective serotonin reuptake inhibitors SSRIs), that have revolutionized the treatment. They are highly effective and produce milder side effects than older medications.

Hormonal abnormalities. Depressed people have an imbalance of hormones, possibly fuelled by a chronic activation of the hypothalamic-pituitary-adrenal axis-the system that manages the body’s response to stress. They generally have higher than normal levels of corticotropin-releasing factor, ACTH, and cortisol, and this may affect the mood. In addition, depression has also been linked to both a deficient or overactive thyroid gland.

Role of other organic disorders. A variety of organic conditions have a link with depression. Deficiencies of vitamin B6, vitamin B12, and folic acid; degenerative neurological disorders, such as Alzheimer’s disease and Huntington’s chorea; strokes in the frontal part of the brain, and certain viral infections are some of them.

Medication as the culprit. A variety of medications, which include those given for pain relief, some antibiotics and anti-fungals, blood pressure lowering medicines, steroids, oral contraceptives, anti-ulcer drugs, and several others may also cause depression in some cases.

Genetic Factors

Both depression and bipolar disorder are known to run in families. The evidence for heredity is much stronger for bipolar illness than for unipolar depressive illness. If a parent has bipolar disorder, there is a 27 per cent chance that his or her child will have a mood disorder. The risk goes up to 50 to 75 per cent if both parents suffer from the illness.

The role of genetic factors in the genesis of depression also finds corroboration in twin-studies. Genetically identical twins, raised in the same environment, are likely to suffer from depression three times more than the non-identical twins who only have about half of the genes in common. Adoption studies also support this theory. These studies show that children of depressed parents are vulnerable to depression even when raised by adoptive parents. On the other hand, children of healthy parents fostered by. depressed adoptive parents need not suffer depression.

Psychological Factors

Stressful life events and depression. Stressful life experiences may play a significant role in the genesis of depression. According to reliable data, the loss of a parent before age 11 is the most significant event associated with the development of depression in later years. The loss of a spouse or some other loved one is also a common environmental stressor that may trigger depression. Other stressful experiences include divorce, pregnancy, the loss of a job, and even childbirth. Many women experience a postpartum depression, after delivering a baby. The transition from one stage in life to the next, such as adolescence, adulthood, middle age and old age, also puts individuals at an increased risk of depression. Women in particular are at risk in middle life, when the children leave home to make their separate existences. Likewise, retirement is another such time, especially for people who derive satisfaction, status, or esteem from their jobs. Serious physical illnesses or disabilities can also be a real burden for some and lead to depression.

Personality factors. All humans, of whatever personality pattern, can and do get depressed, but people with depressive personality traits appear to be more vulnerable. Depressive personality traits include gloominess, pessimism, introversion, self-criticism, excessive scepticism and criticism of others, deep feelings of inadequacy, and excessive brooding and worrying. In addition, people who regularly behave in dependent, hostile, and impulsive ways also appear to run a greater risk of this illness.

Psychoanalytic links. Sigmund Freud believed that depression was a psychological response to loss-either real loss, such as the death of a parent or spouse, or symbolic loss, such as the failure in achieving an important goal. Freud believed that a person’s unconscious anger over such loss leads to a weakening of the ego and the loss of energy.

Theory of ‘learned helplessness’. When animals were exposed during experimental work to repeated electric shocks from which they could not escape, they soon developed an attitude of helpless resignation and made no attempt to escape from future shocks. Basing on these experiments, psychologists have proposed that human beings, when exposed to uncontrollable and inescapable events for long, also develop a similar attitude of ‘learned helplessness’-that, one cannot control the outcome of events. This leads to apathy, pessimism and loss of motivation-the characteristic symptoms of depression.

Cognitive theory. Some people habitually tend to focus only on the negative aspects of any given situation; they interpret facts in negative ways and blame themselves for all misfortunes. This is a negative, self-defeating attitude which often takes roots in early childhood. It makes situations seem much worse than they really are and increases the risk of depression, especially in stressful situations.

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Never trust in the popular theory which claims that a person with a strong will can shake off or will away his or her depression. If it were that simple, the incidence of depression would be much lower. If you suspect that you have a depressive illness or feel that a family member or friend is similarly affected, seek help. See a mental health physician. Without proper treatment the illness usually runs a long course.

Effective treatment is possible with the help of antidepressant medications, psychotherapy, or a combination of both. Unless the illness is severe and carries the risk of self-injury, suicide, or violence to others, or the support system of the person is weak, the treatment can be done at home. Few people require hospitalization.

Medication

Antidepressant medications. Medications that can lift up the mood are the mainstay of the treatment. About 70 to 80 per cent of people with acute depression respond to them, but it generally takes at least two to three weeks before these medications become effective. They primarily work by restoring serotonin, norepinephrine, and other neurotransmitters in the brain to normal levels.

Antidepressant medications are not addictive, but they may produce unwanted side effects, which differ with each medication. They must be taken on a regular basis for several months and sometimes longer to avoid relapse. People who discontinue treatment midway or immediately after their symptoms improve usually run into depression again.

The commonly used anti­depressant medicines fall into four major classes: tricyclics, tetracyclics, monoamine oxidase inhibitors(MAG inhibitors), and selective serotonin reuptake inhibitors (SSRIs).

Tricyclics, named for their three-ring chemical structure, include imipramine, nortriptyline, doxepin, amitriptyline, trimipramine, dothiepin and clomipramine. Side effects of tricyclics may include drowsiness, palpitation, dizziness upon standing, blurred vision, constipation, dry mouth, and confusion.

Tetracyclics have a four-ring chemical structure, and include mianserin and mirtazapine. Their possible adverse effects may range from weakness, flu-like symptoms, back pain, increased appetite, weight gain, constipation and dry mouth. There may also be abnormal dreams, abnormal thinking, tremors and confusion.

MAO inhibitors which include moclobemide have largely been discarded in favour of the safer alternatives. They can lead to many of the same side effects as tricyclics, and also carry the risk of a serious interaction with tyramine, a substance found in wine, beer, some cheeses, ripe bananas and many fermented foods. This can lead to a dangerous rise in blood pressure. People who take MAG inhibitors must therefore follow a diet that excludes tyramine.

SSRIs include fluoxetine, sertraline, paroxetine, and venflaxine. These drugs generally produce fewer and milder side effects than the other types of antidepressants, although they may cause anxiety, insomnia, drowsiness, headaches and sexual dysfunction. Antidepressant medication takes time to show any benefit. Although some signs of change may be evident in as little as two weeks, full benefit may require six weeks or more. This lengthy process may be a little discouraging to the patient. It is important that the family members provide the support and encouragement during this time. The treatment should be taken for at least six months, but it may have to be continued for a longer time. Antidepressants must never be stopped abruptly; the dose has to be gradually reduced before it is discontinued.

Lithium. Lithium carbonate, a natural mineral salt, has been used in the treatment of bipolar disorder since 1949. The treatment is started after admitting the person if the person is unwell. It may also be prescribed during periods of relatively normal mood to delay or even prevent subsequent mood swings. Side effects of lithium include nausea, stomach upset, vertigo and frequent urination. Regular estimation of plasma lithium is necessary to check adverse effects such as impairment of thyroid function.

Other medications. Even though lithium still remains the standard medication for bipolar disorder, a variety of other medications including carbamazepine, valproic acid, and verapamil have also been found useful.

Psychotherapy

Psychotherapy can be an effective treatment for a mild to moderate depression. There are many kinds of psychotherapy. While some forms of psychotherapy try to help people resolve their internal, unconscious conflicts, other forms teach people skills to correct their abnormal behaviour. Studies have shown that psychotherapy scores over anti­depressants in at least two ways-it is free of physiological side effects, and leaves a lasting benefit with a lower relapse rate than if the treatment is solely dependant upon antidepressant medication. However, psychotherapy usually takes longer to produce benefits and studies have found that a combination of psychotherapy with medication works best.

Interpersonal therapy. Interpersonal therapy is a short-term psychotherapy, normally consisting of 12 to 16 weekly sessions. It has been developed to treat people with unipolar depressive illness on an out patient basis. The therapist helps a person resolve problems in relationships with others that may have caused the depression. The subsequent improvement in social relationships and support helps alleviate the depression.

Cognitive-behavioural therapy. The cognitive theory assumes that depression stems from negative, often irrational thinking about oneself and one’s future. In this type of therapy, a person learns to understand and eventually eliminate those habits of negative thinking. The goal of cognitive therapy is to alleviate depression and prevent its recurrence by developing more positive and flexible ways of thinking.

Psychoanalytically oriented therapy. The psychoanalytic therapy aims at effecting a change in the personaliry structure or character, and not just at alleviating the symptoms. This therapy focuses upon an improvement in the person’s interpersonal trust, intimacy with others, development of coping mechanisms, the capaciry to grieve, and the abiliry to experience a wide range of emotions.

Behaviour therapy. Several behaviour therapies have been developed for the depression treatment. The goal is to bring about a change in behaviour so that the patient does not relapse due to a faulry behaviour pattern.

Electro-convulsive therapy

Electro-convulsive therapy is effective in both major depression and bipolar disorder. It is found to be particularly useful in people who suffer from severe depression and are suicidal, and also in those who fail to respond to antidepressant medication and psychotherapy. In this type of therapy, a low-voltage electric current is passed through the brain for a few milliseconds to produce a controlled seizure. Usually six to ten treatments are needed, spread over a few weeks.

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Depression can appear at anytime in anybody. The illness may begin slowly and it may deepen gradually over months or years, or may spark off all of a sudden over a few days or weeks.

Often at first the sufferer is so taken up with negative thoughts, and the feelings of sadness, hopelessness and helplessness are so overwhelming that the family feels the person has had a nervous breakdown. He or she may cry for hours together, think that life is not worth living, and may not feel pleasure in meeting with people, or engaging in work and activities that used to bring him or her happiness at one time. Thoughts of death and suicide may dominate over him or her and he or she may constantly demand company and support.

A depressed person’s body language also tells the story. A stooped posture, lack of spontaneous movements, and a downcast, averted gaze is the classic description.

The symptoms of depression may vary with age. In younger children, a depressive disorder may present with vague physical complaints, such as stomachaches and headaches, as well as changes in eating habits, irritability, social withdrawal, and isolation. Such children show a lack of enthusiasm. They do not feel happy about taking part in any activity or in attending school.

In adolescents, common symptoms include sad mood, sleep disturbances, and lack of energy. They may also experience sudden mood swings. Adults may suffer similar symptoms, including changes in appetite, sleep, and energy level, sadness, loss of self-esteem, and the lack of volition. Many people suffer from physical problems. This is also the case with elderly people. They may unconsciously believe that physical complaints are more likely to win attention and treatment, but often the attending physicians fail to diagnose the emotional problem. Often, the signs of depression are thought of as eccentricity and dismissed summarily as a part of ageing, and the family members may fail to recognize the symptoms.

The classic symptoms of depression include:

Poor self-esteem. People with depression often suffer from a persistent feeling of worthlessness, helplessness, guilt, and self-blame. They may interpret a minor failing on their part as a sign of incompetence, or interpret minor criticism as condemnation. Even a competent and decent person may feel deficient, useless, stupid, or guilty of having deceived others.

Negative thoughts. Added to the negative perception of self, depressed people also tend to take a persistent negative view of the world. This may turn them into a social recluse. They may draw away from all activity and typically become slow and monosyllabic in their response.

Lasting sadness. A feeling of overwhelming sadness may swallow up the person’s routine. He may weep silently and suffer from black despair. Nothing seems to please him and he does not enjoy the activities that used to give him profound pleasure.

Inability to take decisions. Depressed people often suffer from irritability and mood swings. They have difficulty in thinking clearly, suffer from slowness of thought, lack concentration, and find it difficult to take any decisions.

Persistent lack of energy. Depression also leads to a drop in one’s energy level. Depressed people generally experience great fatigue, lack of energy, and a feeling of being worn out or overburdened.

Bodily symptoms. A number of depressed people complain of bodily symptoms such as headaches, stomachache, weakness, and fatigue. Generally, these people end up going through a number of clinical tests without any useful result and continue to suffer because the physician cannot figure out their root problem.

Loss of appetite or overeating. Depression usually alters a person’s appetite. While some depressed people take to overeating, more often they just stop to eat or eat barely to survive. This leads to a loss of weight. Depressed people may also suffer from indigestion, constipation, or diarrhoea.

Changes in sleep habits. People with depression may oversleep. But, more commonly, they have difficulty in falling asleep and also staying asleep. A depressed person thus might go to sleep at midnight, sleep restlessly, and then wake up after two or three hours of sleep feeling tired and gloomy. This recurrent early morning awakening at 3AM or 4AM is a typical sign of depression.

Loss of interest in sex. The negative emotions also play havoc wjth the love life of the depressed people. They may lose all interest in sex and this may also affect their marriage.

Suicidal thoughts and risk. A major depression can lead to such extreme emotional distress that people may contemplate or attempt suicide. Some 15 per cent of the seriously depressed people do commit suicide, and many more attempt it.

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