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Depression in Younger People- a patient's guide
Dr Sally Merry -Child Psychiatrist
What is depression? Doesn't everybody get depressed
sometimes?
We all have times when we feel sad or stressed. There
are times when day to day problems get us down. However
these feelings are usually short-lived. This is not depression!
When doctors use the term "depression" they are talking
about an ongoing serious situation in which a person feels
down most of the time for a long period, weeks or months,
and sometimes years. When this happens it makes it difficult
to keep up with everyday things. Work, school and social
life can all be affected. Depression has an impact on appetite,
sleep and the ability to concentrate and think clearly.
Depression is also called "depressive illness", "major depressive
disorder", "dysthymia' or "clinical depression".
Do children and teenagers get depressed?
We used to think that depression was something that only
affected adults but over the last few years we have realised
that depression can affect people at any age. Depression
is not very common before the teenage years and children
who get depressed usually do so because of the situation
they are in. For example if the family is going through
a hard time then the children in that family may become
so miserable that is affects their ability to function.
Through the teenage years rates of depression increase
markedly, especially in girls, so that by the age of 18
as many as one in five teenagers will have had an episode
of depression, which is mostly untreated. We are not good
at recognising depression generally, and we are especially
poor at recognising it in teenagers. Part of the problem
is that we expect teenagers to go through a difficult time.
We expect them to be moody and irritable. However research
has shown that while the teenage years can be unsettled,
for the most part teenagers get through their adolescence
reasonably well. We should not just accept it if a teenager
feels miserable or irritable for most of the time, especially
if this is making school and socialising difficult. We can
improve things for these young people as we have developed
very effective treatments for depression.
What causes depression?
Usually depression is the result of a number of things
coming together and it is impossible to put it down to some
simple factor. The causes of depression can be grouped into
biological, psychological and social.
Biological
Depression is associated with a change in chemicals in
the brain called neurotransmitters, which pass messages
from one nerve cell to another. The two main neurotransmitters
thought to be related to depression are serotonin and noradrenaline.
These are decreased in people who are depressed. Medication
works by increasing these substances.
Depression runs in families so that some people are born
with an increased risk of developing depression. This tendency
can be mild or severe and may only show itself if some of
the other factors associated with depression come into play.
For example someone who has family members who have suffered
from depression may be more at risk for a depressive illness
following a relationship break-up. In this way it is similar
to illnesses like asthma, which also runs in families, can
affect some more than others, and some not at all, and where
the asthma attack is often set off by something like coming
into contact with pollen, or the dust mite.
Psychological
We often think of feelings as things that happen to us
over which we have no control. In fact the way we think
about things affects the way we feel. People who have tendency
to become depressed often feel very negative about themselves,
about the world around them and about the future. They see
little that is positive. Compared with someone who is not
depressed they will tend to come up with more negative explanations
for things that happen and are more likely to blame themselves
when things go wrong.
People who are depressed are less likely to look for solutions
to problems than people who aren't. They tend to give up
more easily. This may be the result of stress early in life
or it may be that they have just never learned skills to
help them to solve problems.
These psychological findings are important as they have
led to the development of highly effective psychological
therapies.
Social
There are many stressful life circumstances that may contribute
to depression. Family discord has been shown to be related
to depression in children and young people. Other things
that may contribute include loss experiences like losing
a parent early in life, illness, especially chronic severe
illness, abuse, and major trauma. War, colonisation and
oppression may affect the mental health of large numbers
of people in certain ethnic groups.
How to recognise depression
The sign of depression are:-
Low mood or irritability most of the time for more than
two weeks
Difficulty with concentration
Change in sleep, either an increase or a decrease
Change in appetite, either an increase or a decrease
A drop in school grades
Reduced contact with friends
Loss of interest in usual activities
Suicidal thoughts or ideas
There is a self-test questionnaire at the end of this
article which gives an indication of severity of depression
if you are worried about yourself or someone else.
Treatment for depression
If you or someone you know is depressed there are a number
of simple things that might help:
Being busy tends to improve mood. Even if it is an effort
to begin, it is good to set goals and try and achieve them.
If it is very hard going small goals are fine.
Scheduling enjoyable things is a good thing to do. Phoning
a friend, playing sport, having a bath with music and candles,
going to a movie, listening to music, watching a favourite
TV programme are all things that may improve mood.
Getting enough sleep and eating sensibly are important.
Exercise improves mood. It increases the neurotransmitter
serotonin, which is decreased in depressed people.
Telling someone about the problem is usually helpful.
It allows someone to give support and they may have some
good ideas for improving difficulties.
It is important to avoid alcohol, marijuana and sedatives
generally. While these may make things better in the short-term
they are depressants of the nervous system and will make
depression worse. Illegal drugs generally have an adverse
effect on people who are depressed.
You might like to try the self-help website www.feelbetter.org
Where to go for help
If all these thing have been tried and there isn't improvement
within a couple of weeks it is worth getting help. The best
place to start is with your family doctor or school guidance
counsellor who should be able to help, or to refer you to
someone who can. Most places now have community child and
adolescent mental health services that provide help for
a variety of problems. You need a referral for many of these
centres (which are listed in the phone books under mental
health services in the hospital section of the telephone
directory) but some will let you refer yourself. Staff at
the centres will be able to give you advice about where
to start in your particular area.
What treatments are available
There are a number of treatments available for depression.
When deciding what treatment to use it is important that
there is some evidence that the treatment works. This is
important in treating physical illness like asthma and diabetes.
It is also important in the treatment of mental illness.
In depression there are many treatments described and used
and not all of these have been tested well to see if they
are working. They may be effective but there may not be
any evidence for it yet. It is better to use a treatment
which has been tested and is known to be effective.
What treatments work?
We have evidence that we can treat depression effectively
and are able to improve things for 8 out of 10 young people.
The treatments for which we have the best evidence are cognitive
behavioural therapy (and the evidence is best for this),
specific antidepressants and interpersonal therapy.
Cognitive behavioural therapy (CBT)
This therapy is based on the psychological factors that
contribute to depression. It has two main components the
cognitive, which deals with how people think and the behavioural,
which addresses how people behave. It is essentially a systematic
training in positive thought and action. It is a very practical
therapy. Young people and their families are taught about
depression and its causes. Mood is affected by what we think
and what we do. Attention is paid to day to day activities
and how they affect emotions. Activities that improve mood
are scheduled. Negative ways of thinking are identified
and more helpful ways of thinking are found. The person
who does the therapy is the young person. The mental health
professional is like a coach. It takes 12 - 16 sessions
that last about one hour each. Sometimes it is done in groups.
CBT has been shown to work in adults and teenagers and probably
helps to prevent depression coming back.
Medication
The most useful medications for young people with depression
are called the SSRI's (specific serotonin re-uptake inhibitors).
They work by increasing the brain chemical serotonin. They
are effective in young people but take two to three weeks
to work. They are taken once a day, usually in the morning.
They are very safe medications and are not addictive but
need to be stopped gradually so that the body can adjust
to not having them. Side effects are worst in the first
couple of weeks and this is a difficult time as the depression
has not improved. It may be tempting to stop the medication
in these early days but persevering with it is mostly worthwhile.
Side effects improve with time. The most common side- effects
are nausea, anxiety, difficulty sleeping, or excessive sleepiness.
If one of these is too troublesome a change to another SSRI
can sometimes sort things out. If medication has an effect,
it should then be continued for at least six months before
being stopped. Common SSRI's include fluoxetine (Prozac,
Lovan), paroxetine (Aropax) and citalopram (Cipramil).
Interpersonal therapy
This is a psychological therapy that focuses on how the
young person relates to those around him/her. It looks at
ways that the young person can improve relationships with
others. Theoretically it should work well, as we all know
that conflict with those around us can make us feel negative
and miserable. There is some evidence that it works for
both young people and adults.
Cognitive behavioural therapy and medication work about
as well as each other and if they are combined work better
than either alone. As well as these therapies it may be
important to address other things. Family conflict is an
especially important area to deal with. If there are problems
at school then these need to be dealt with. Specific counselling
may be needed for specific difficulties such as abuse. Teenagers
often abuse substances such as alcohol and marijuana. This
will make the depression worse and will need specific attention.
While there are many other therapies used for depression,
and some of these may be effective, we do not yet have scientific
evidence that they work.
It is important to know that improvement takes time. Any
therapy may take three or more weeks to start working and
it can take two to three months before things get substantially
better.
What happens over time?
If depression is not treated it can last for months or
years. Once treated there is a high chance it will return
(up to 70% of those who have had an episode of depression
have another within 5 years). Recognising early signs that
it is returning and managing these actively can reduce relapse
rates markedly.
Depression and suicide
We (in New-Zealand) have one of the highest rates of youth
suicide in the world. Parents are concerned for their teenagers
and yet often feel powerless. Information about suicide
and suicide attempts may be helpful.
Despite the media coverage or anecdotes it is known that
over 90% of those who attempt or complete suicide have some
form of mental illness. The most common illness is depression
and it is mostly untreated. Other important problems include
alcohol and drug abuse, aggressive and impulsive behaviour
and high rates of family and social problems. It is important
to realise that although our suicide statistics are high,
suicide is still not common. In 1998 the rate for young
men was 4 out of every 10 000 young men. Suicidal thoughts
are very common in young people, some will attempt suicide
and only a very small minority will complete suicide.
What can be done?
Suicidal thoughts are more common in young people who
are depressed and it is important to talk about them. Many
people are afraid that they may make things worse by talking
about suicide. This is partly because we know that publicity
about suicide can lead to an increase in those who kill
themselves. There are some clear examples of young people
killing themselves after suicide has been the topic in television
shows or after a pop star has committed suicide. However
there is no evidence that talking about suicidal thoughts
with young people on an individual basis and out of concern
for the young person leads to suicide or suicide attempts.
It is an important part of managing young people who are
suicidal and mental health professionals do it all the time.
If you are feeling suicidal, tell someone! If you are worried
that someone is suicidal, ask him/her! If the feelings are
strong, get help! Your family doctor, a school guidance
counsellor, a priest, a trusted older person are all good
places to start. Where there is depression, effective treatment
can usually get rid of the suicidal thoughts or at least
reduce them to the point where they are not too troublesome.
Many of the other underlying problems that contribute to
suicidal thoughts can also be improved. It is better to
address the problem than to hope it will solve itself.
Summary
Depression is common and usually starts in the teenage
years. It is caused by a mix of factors including an inborn
tendency, changes in chemicals in the brain, family and
social problems and a pessimistic way of thinking. It is
linked to poor school performance, difficulty with relating
to other people, abuse of drugs and alcohol and suicide.
Untreated, it goes on for months or years. There are effective
treatments for over 80% of people with depression with cognitive
behavioural therapy and medication the treatments of choice
at the moment. There is a high rate of relapse so that it
is important that any one who has suffered from depression
knows how to recognise signs that it is coming back and
how to deal with it if it recurs.
Test Your Depression
To determine how depressed you are, take this widely used
test called CES-D (Center for Epidemiology Studies-Depression).
It was developed by Lenore Radloff at the Center for Epidemiological
Studies of the National Institute of Mental Health.
Write down the score for the answer that best describes
how you have felt over the past week.
1. I was bothered by things that usually don't bother
me.
0 Rarely or none of the time (less than 1 day)
1 Some or a little of the time (1-2 days)
2 Occasionally or a moderate amount of the time (3-4 days)
3 Most or all of the time (5-7 days)
2. I did not feel like eating; my appetite was poor.
0 Rarely or none of the time (less than 1 day)
1 Some or a little of the time (1-2 days)
2 Occasionally or a moderate amount of the time (3-4 days)
3 Most or all of the time (5-7 days)
3. I felt that I could not shake off the blues even
with help from my family and friends.
0 Rarely or none of the time (less than 1 day)
1 Some or a little of the time (1-2 days)
2 Occasionally or a moderate amount of the time (3-4 days)
3 Most or all of the time (5-7 days)
4. I felt that I was not as good as other people.
0 Rarely or none of the time (less than 1 day)
1 Some or a little of the time (1-2 days)
2 Occasionally or a moderate amount of the time (3-4 days)
3 Most or all of the time (5-7 days)
5. I had trouble keeping my mind on what I was doing.
0 Rarely or none of the time (less than 1 day)
1 Some or a little of the time (1-2 days)
2 Occasionally or a moderate amount of the time (3-4 days)
3 Most or all of the time (5-7 days)
6. I felt depressed.
0 Rarely or none of the time (less than 1 day)
1 Some or a little of the time (1-2 days)
2 Occasionally or a moderate amount of the time (3-4 days)
3 Most or all of the time (5-7 days)
7. I felt that everything I did was an effort.
0 Rarely or none of the time (less than 1 day)
1 Some or a little of the time (1-2 days)
2 Occasionally or a moderate amount of the time (3-4 days)
3 Most or all of the time (5-7 days)
8. I felt hopeless about the future.
0 Rarely or none of the time (less than 1 day)
1 Some or a little of the time (1-2 days)
2 Occasionally or a moderate amount of the time (3-4 days)
3 Most or all of the time (5-7 days)
9. I thought my life had been a failure.
0 Rarely or none of the time (less than 1 day)
1 Some or a little of the time (1-2 days)
2 Occasionally or a moderate amount of the time (3-4 days)
3 Most or all of the time (5-7 days)
10. I felt fearful.
0 Rarely or none of the time (less than 1 day)
1 Some or a little of the time (1-2 days)
2 Occasionally or a moderate amount of the time (3-4 days)
3 Most or all of the time (5-7 days)
11. My sleep was restless.
0 Rarely or none of the time (less than 1 day)
1 Some or a little of the time (1-2 days)
2 Occasionally or a moderate amount of the time (3-4 days)
3 Most or all of the time (5-7 days)
12. I was unhappy.
0 Rarely or none of the time (less than 1 day)
1 Some or a little of the time (1-2 days)
2 Occasionally or a moderate amount of the time (3-4 days)
3 Most or all of the time (5-7 days)
13. I talked less than usual.
0 Rarely or none of the time (less than 1 day)
1 Some or a little of the time (1-2 days)
2 Occasionally or a moderate amount of the time (3-4 days)
3 Most or all of the time (5-7 days)
14. I felt lonely.
0 Rarely or none of the time (less than 1 day)
1 Some or a little of the time (1-2 days)
2 Occasionally or a moderate amount of the time (3-4 days)
3 Most or all of the time (5-7 days)
15. People were unfriendly.
0 Rarely or none of the time (less than 1 day)
1 Some or a little of the time (1-2 days)
2 Occasionally or a moderate amount of the time (3-4 days)
3 Most or all of the time (5-7 days)
16. I did not enjoy my life.
0 Rarely or none of the time (less than 1 day)
1 Some or a little of the time (1-2 days)
2 Occasionally or a moderate amount of the time (3-4 days)
3 Most or all of the time (5-7 days)
17. I had crying spells.
0 Rarely or none of the time (less than 1 day)
1 Some or a little of the time (1-2 days)
2 Occasionally or a moderate amount of the time (3-4 days)
3 Most or all of the time (5-7 days)
18. I felt sad.
0 Rarely or none of the time (less than 1 day)
1 Some or a little of the time (1-2 days)
2 Occasionally or a moderate amount of the time (3-4 days)
3 Most or all of the time (5-7 days)
19. I felt that people disliked me.
0 Rarely or none of the time (less than 1 day)
1 Some or a little of the time (1-2 days)
2 Occasionally or a moderate amount of the time (3-4 days)
3 Most or all of the time (5-7 days)
20. I could not get "going."
0 Rarely or none of the time (less than 1 day)
1 Some or a little of the time (1-2 days)
2 Occasionally or a moderate amount of the time (3-4 days)
3 Most or all of the time (5-7 days)
This test is easy to score. It simply adds up symptoms
of depression. The more you have, the more likely it is
that you are depressed. Add up the numbers you circled.
If you couldn't decide and circled two numbers for the same
question, count only the higher of the two. Your score will
be someplace between 0 and 60.
Before interpreting your score, you should know that a
high score is not the same as a diagnosis of depression.
A few people who get high scores are not in fact depressed,
and people with low scores can still have a "depressive
disorder." A full-blown diagnosis of depression depends
on other things, such as how long your symptoms have lasted
and whether they have some other cause. A diagnosis can
be made only after a thorough interview with a qualified
health professional(family doctor,psychologist or psychiatrist).
Rather than giving a diagnosis, this test gives an accurate
indication of your level of depression right now.
If you scored from 0 to 9, you are in the non-depressed
range, below the average of American adults; 10 to 15 puts
you in the mildly depressed range; and 16 to 24 puts you
in the moderately depressed range. If you scored over 24,
you are probably severely depressed. If you scored in the
severely depressed range, I urge you to seek treatment.
If you believe that you would kill yourself if you had a
chance, regardless of the rest of your answers, I urge you
to see a mental health professional right away. If you scored
in the moderately depressed range and, in addition, you
often think about killing yourself, you should see a professional
right away. If you scored in the moderately depressed range,
take the test again in two weeks. If you still score in
that that range, make an appointment with a mental health
professional.
Resources
Downtimes. Teenage Depression in New Zealand. A Guide
for Young People and their Families. L Andrews, S Merry
& S Van Altvorst. Bateman. 1998.
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