Depression (including psychotic depression)

We all feel fed up, miserable or sad at times. Usually, these feelings are short-lived, and they don't interfere too much with our lives. Sometimes there's a reason, sometimes not. We usually cope; we may talk to a friend but don't otherwise need any help.

In order for someone to be diagnosed with depression, they need to have low mood on most days for at least two weeks, and in most cases, it goes on for much longer than this. The symptoms generally interfere with a person’s functioning and they often have to take time off work. There are a number of physical and psychological symptoms which occur in depression including

feeling unhappy most of the time (but may feel a little better in the evenings)
losing interest in life and can't enjoy anything
finding it harder to make decisions
poor concentration and memory
a feeling of being unable to cope
feeling very tired
feeling restless and agitated
feeling anxious and/or having panic attacks
loss of appetite and weight (some people find they do the reverse and put on weight)
difficulty getting off to sleep, and then waking early in the morning
loss of interest in sex
loss of self-confidence
feeling useless, inadequate and hopeless
avoiding other people
feeling irritable
feeling worse at a particular time each day, usually in the morning
thoughts of suicide

You may not realise how depressed you are for a while, especially if it has come on gradually. You try to struggle on and may even start to blame yourself for being lazy or lacking willpower.

It sometimes takes a friend or a partner to persuade you that there really is a problem which can be helped. If you have suffered from depression before, you may recognise some of the symptoms yourself or someone close to you may notice “early warning signs”.

Why does depression happen?

As with our everyday feelings of low mood, there will sometimes be an obvious reason for becoming depressed, sometimes not. It can be a disappointment, a frustration, or a loss event, such as loss of something or someone important to you. There is often more than one reason, and these will be different for different people. They include

Things that happen in our lives

It is normal to feel a change in mood after a distressing event such as bereavement, a divorce or losing a job. You may well spend a lot of time over the next few weeks or months thinking and talking about it. After a while you come to terms with what's happened. But you may get stuck in a depressed mood, which doesn't seem to lift.

Circumstances

Certain life circumstances can increase the risk of depression. These include living in poverty, living alone, lack of social support, chronic stress, chronic unemployment and physical illness.

Physical Illness

The following can increase the risk of depression

life-threatening illnesses like cancer and heart disease
long and/or painful illnesses, like arthritis
viral infections like 'flu' or glandular fever - particularly in younger people
hormonal problems, like an under-active thyroid
strokes

Personality

Certain personality types are more at risk of depression, for example people with anxious personalities or obsessional personality traits. People with personality difficulties/ disorders, often related to childhood abuse, are also more at risk of depression.

Alcohol

Regular heavy drinking makes you more likely to get depressed – and, indeed, to kill yourself. Conversely, people with chronic depression sometimes turn to alcohol and illicit drugs as a means of coping with the symptoms.

Gender

Women seem to get depressed more often than men, however there is a higher rate of suicide in men, particularly among young and middle-aged men. It may be that men are less likely to talk about their feelings, and more likely to deal with them by drinking heavily or becoming aggressive. Women are more likely to have the double stress of having to work and look after children.

Genes

Depression can run in families. If you have one parent who has become severely depressed, you are about eight times more likely to become depressed yourself. This includes a parent with a history of bipolar illness.

What about bipolar disorder (manic depression)?

About one in ten people who suffer from serious depression will also have periods when they are abnormally happy and overactive. This used to be called manic depression but is now called Bipolar Disorder. It affects the same number of men and women and tends to run in families. Bipolar disorder occurs in one to two percent of the population.

When should I seek help for depression?

When your feelings of depression are persistent, difficult to deal with and don't seem to get any better.
When your feelings of depression affect your work, interests and feelings towards your family and friends.
If you find yourself feeling that life is not worth living, or that other people would be better off without you.
If you have thoughts of suicide.

It is a good idea to tell someone close to you that you are feeling depressed. They should encourage you to make an appointment with your GP. Your GP will take a history of your symptoms and try to establish what triggered the condition. They may arrange routine blood tests to exclude an underlying physical cause.

If your depression is severe and/ or if there are concerns about your risk of suicide, you are likely to be referred to your local mental health service. You will be assessed by a mental health practitioner or a psychiatrist.

If you are concerned about the depth of your depression, if you are feeling increasingly suicidal or if you are on the verge of attempting suicide, you must seek immediate medical help. You should attend your local Accident and Emergency department.

Self-help for depression

If you've had some bad news, or a major upset, tell someone close to you; tell them how you feel. You may need to talk (and maybe cry) about it more than once. This is part of the mind's natural way of healing.

Do something

Get out of doors for some exercise, even if only for a walk.

This will help you to keep physically fit and will help you sleep. Even if you can't work, it's good to keep active.

This could be housework, do-it-yourself (even as little as changing a light bulb), or any activity that is part of your normal routine.

Eat well

You may not feel like eating - but try to eat regularly.

Depression can make you lose weight and run short of vitamins which will only make you feel worse. Fresh fruit and vegetables are particularly helpful.

Beware alcohol!

Try not to drown your sorrows with a drink. Alcohol actually makes depression worse. It may make you feel better for a short while, but it doesn't last.

Drinking can stop you dealing with important problems and from getting the right help. It's also bad for your physical health.

Beware cannabis

While cannabis can help you to relax, there is now evidence that regular use, particularly in teenagers, can bring on depression.

Sleep

If you can't sleep, try not to worry about it. Settle down with some relaxing music or television while you're lying in bed.

Your body will get a chance to rest and, with your mind occupied, you may feel less anxious and find it easier to get some sleep.

Tackle the cause

If you think you know what is behind your depression, it can help to write down the problem and then think of the things you could do to tackle it. Pick the best things to do and try them.

Keep hopeful

Remind yourself that:

Many other people have had depression.
It may be hard to believe, but you will eventually come out of it.
Depression can sometimes be helpful – you may come out of it stronger and better able to cope. It can help you to see situations and relationships more clearly.
You may be able to make important decisions and changes in your life, which you have avoided in the past.

What kind of help is available for depression?

Most people with depression are treated by their GP. Depending on your symptoms, the severity of the depression and the circumstances, your doctor may suggest:

self-help
talking treatments
antidepressant drugs

Guided self-help

This can include:

Self-help leaflets or books, using Cognitive Behavioural Therapy (CBT) principles
Self-help computer programmes or the internet
Exercise - 3 sessions per week for 45 minutes to 1 hour, for between 10 and 12 weeks

Whichever of these is right for you depends on your personality and lifestyle.

Talking treatments

There are many different sorts of psychotherapy available, some of which are very effective for people with mild to moderate depression. They include:

Counselling

Simply talking about your feelings can be helpful, however depressed you are. Sometimes it is hard to express your real feelings even to close friends.

Talking things through with a trained counsellor or therapist can be easier. It can be a relief to get things off your chest, and it can help you to be clearer about how you feel about your life and other people.

There may be a counsellor at your GP surgery with whom you can talk, or your GP can refer you to a local counselling service.

Cognitive behavioural therapy (CBT)

Many of us have habits of thinking which, quite apart from what is happening in life, are likely to make us depressed and keep us depressed. CBT helps you to:

identify any unrealistic and unhelpful ways of thinking
then develop new, more helpful ways of thinking and behaving.

Problem-solving therapy

This helps you to be clear about your key problems, how to break them down into manageable bits and how to develop problem-solving skills.

Couple therapy

If your depression seems connected with your relationship with your partner, then RELATE can be helpful in enabling you to sort out your feelings – it is an organisation that specialises in working with couples (see 'other organisations' for contact details).

Support groups

If you have become depressed while suffering from a disability or caring for a relative, then sharing experiences with others in a self-help group may give you the support you need.

Bereavement counselling

If you are not able to get over the death of someone close to you, you need to talk about it with a specialist bereavement counsellor.

Interpersonal and psychodynamic psychotherapy

This may be more suitable if you have had long-standing difficulties with your life or relationships. This tends to be a longer-term treatment and helps you to see how your past experiences may be affecting your life here and now.

Group therapy

Talking in groups can be helpful in changing how you behave with other people. You get the chance, in a safe and supportive environment, to hear how people see you, and the opportunity to try out different ways of behaving and talking.

Talking treatments do take time to work. Sessions usually last about an hour and you might need anywhere from five to 30 sessions. Some therapists will see you weekly, others every two to three weeks.

Problems with talking treatments

These treatments are usually very safe, but they can have unwanted effects. Talking about things can bring up bad memories from the past and this can make you feel worse for a while. Others have reported that therapy can change their outlook and the way they relate to friends and family.

Therapy can put a strain on a close relationship. Make sure that you can trust your therapist and that they have the necessary training. If you are concerned about having therapy, talk it over with your doctor or therapist. Unfortunately, talking treatments are still in short supply. In some areas, you may have to wait for several months.

Antidepressants

If your depression is moderate or severe or goes on for a long time, your doctor may suggest a course of antidepressants.

These are not tranquillisers, although they may help you to feel less anxious and agitated. They can help people with depression to feel and cope better, so that they can start to enjoy life and deal with their problems effectively again.

Although there is a continuing debate about how much more effective they are than placebo (‘dummy drug’), they seem to be most helpful in more severe depressions.

If you do start taking antidepressants, you probably won't feel any effect on your mood for two or three weeks. You may notice that you start to sleep better and feel less anxious after a few days.

How do antidepressants work?

The brain is made up of millions of cells which transmit messages from one to another using tiny amounts of chemical substances called neurotransmitters. Upwards of 100 different chemicals are active in different areas of the brain.

It is thought that in depression, two of these neurotransmitters are particularly affected – Serotonin, sometimes referred to as 5HT, and Noradrenaline.

Antidepressants increase concentrations of these two chemicals at nerve endings, and so seem to boost the function of those parts of the brain that use Serotonin and Noradrenaline. Even so, it is not certain that this is the actual mechanism that improves your mood.

Problems with antidepressants

Like all medicines, antidepressants have side-effects, though these are usually mild and tend to wear off after a couple of weeks.

The newer antidepressants (called SSRIs) may make you feel a bit sick at first, and you may feel more anxious for a short while. The older type of antidepressants can cause a dry mouth and constipation.

Your doctor can advise you on what to expect and will want to know about anything that worries you. You will also get written information on the medication from your pharmacist.

If an antidepressant makes you sleepy, you should take it at night, so it can help you to sleep.

However, if you feel sleepy during the day, you should not drive or work with machinery until the effect wears off. Alcohol can make you very sleepy if you drink while taking the tablets, so it is best avoided.You can eat a normal diet while taking most of these tablets.

Your GP, not a psychiatrist, will usually be the one who prescribes an antidepressant. At first, he or she will need to see you regularly to make sure the tablets agree with you. If they do help, it is advisable to stay on them for at least 6 months after you feel better.

If you have had more than one episode of depression, you may have to stay on them for longer than this. When it is time to stop, you should come off them slowly with the advice of your doctor.

People often worry that antidepressants are 'addictive'. Certainly, you may get withdrawal symptoms if you stop an antidepressant suddenly.

These can include anxiety, diarrhoea and vivid dreams or even nightmares. This can nearly always be avoided by slowly reducing the dose before stopping.

Unlike drugs such as Valium (or nicotine or alcohol), you don't have to keep taking an increasing amount to get the same effect, and you will not find yourself craving an antidepressant.

Antidepressants and young people

There are some limits to the use of antidepressants for younger people in their teens. There is some evidence that SSRI antidepressants can increase suicidal thoughts in young people, so there are limits on their use in this age group. In the UK:

Fluoxetine is the only SSRI antidepressant licensed for use with young people.
It should usually be used only in addition to a psychological therapy.
It should be given under the direction of a psychiatrist.
The young person should be seen every week at least for the first 4 weeks.

Alternative remedies

St John's Wort is a herbal remedy available from chemists. It is widely used in Germany and there is evidence that it is effective in mild to moderate depression. There are now one-tablet per day preparations available.

It seems to work in much the same way as some antidepressants, but some people find that it has fewer side-effects. One problem is that it can interfere with the way other medications work. If you are taking other medication, you should discuss it with your GP.

Which is right for me - antidepressants or talking treatments?

If your depression is mild, then you probably won't need an antidepressant. But if your depression has gone on for a long time, or is affecting you badly, then it may be worth trying an antidepressant at the same time as a course of talking therapy.

People often find that it is useful to have some form of psychotherapy after their mood has improved with antidepressants. It can help you to work on some of the things in your life that might otherwise make you become depressed again.

So, it may not be a case of one treatment or the other, but what is most helpful for you at a particular time.

Both talking treatments and antidepressants are about equally effective in helping people get better from moderate depression. (see references). Many psychiatrists believe that antidepressants are more effective in treating severe depression.

Some people just don't like the idea of medication; some don't like the idea of psychotherapy.

So, there is obviously a degree of personal choice. This is limited by the fact that proper counselling and psychotherapy are not readily available in some areas of the country.

When you are low, it can be difficult to work out what you should do. Talk it over with friends or family or people you trust. They might be able to help you decide.

Do I need to see a psychiatrist for my depression?

Probably not. Most people with depression get the help they need from their GP. If you don't improve and need more specialist help, you will be referred to a psychiatrist or a member of the Community Mental Health Team.

A psychiatrist is a medical doctor who specialises in the treatment of emotional and mental disorders. Community team members may be a nurse, psychologist, social worker or occupational therapist. Whichever profession they belong to, they will have specialist training and experience in mental health problems.

The first interview with a psychiatrist will probably last about an hour. You may be invited to bring a relative or friend with you if you wish.

The psychiatrist will want to find out about your general background, and about any serious illnesses or emotional problems you may have had in the past.

He or she will ask about what has been happening in your life recently, how the depression has developed and whether you have had any treatment for it already.

It can sometimes be difficult to answer all these questions, but they help the doctor to get to know you as a person and to get an idea of what would be good options for you.

This might be practical advice, or suggesting different treatments, perhaps involving members of your family.

If your depression is severe or needs specialist treatment, you might need to come into hospital – but this is only needed for 1 in every 100 people with depression.

What happens if I don't get treatment for my depression?

The good news is that 4 out of 5 people with depression will get completely better without any help in about 4-6 months - sometimes more. So, why bother to treat depression?

Although 4 out of 5 people get better in time, this still leaves 1 in 5 who are still depressed two years later.

As yet, we can't accurately predict who will get better and who will not. Even if you get better eventually, the experience can be so unpleasant that you may feel that you want to shorten the time you are depressed.

Moreover, if you have a first episode of depression, you have a roughly 50:50 chance of having another one. A small number of people with depression will eventually kill themselves.

Taking up some of the suggestions in this leaflet may shorten a period of depression. If you can overcome it by yourself, then that will give you a feeling of achievement and confidence to tackle such feelings again if you feel low in the future.

However, if the depression is severe or goes on for a long time, it may stop you from being able to work and enjoy life.

Electroconvulsive Therapy (ECT)

Electroconvulsive therapy (ECT for short) can be used:

in severe depression, if the person's life is at risk and they need urgent treatment
in moderate or severe depression, when no other treatment has helped.

ECT involves passing an electric current through the brain, so is always given in hospital under general anaesthetic. Some people have memory problems after ECT.

How can I help someone who is depressed?

Listen. This can be harder than it sounds. You may have to hear the same thing over and over again. It's usually best not to offer advice unless it's asked for, even if the answer seems perfectly clear to you. If depression has been brought on by a particular problem, you may be able to help find a solution or at least a way of tackling the difficulty.
It's helpful just to spend time with someone who is depressed. You can encourage them, help them to talk, and help them to keep going with some of the things they normally do.
Someone who is depressed will find it hard to believe that they can ever get better. You can reassure them that they will get better, but you may have to repeat this over and over again.
Make sure that they are buying enough food and eating enough.
Help them to stay away from alcohol.
If they are getting worse and start to talk of not wanting to live or even hinting at harming themselves, take them seriously. Make sure that they tell their doctor.
Encourage them to accept help. Don't discourage them from taking medication or seeing a counsellor or psychotherapist. If you have worries about the treatment, then you may be able to discuss them first with the doctor.

Further help

Reading Well Agency: Books on Prescription

Reading Well Books on Prescription helps you manage your well-being using self-help reading. The scheme is endorsed by health professionals, including the Royal College of Psychiatrists, and is supported by public libraries.

Other organisations

Association for Postnatal Depression: Helpline: 020 7386 0868 (10am- 2pm Mon, Weds and Fri and 10am- 5pm, Tues and Thurs). Provides support to mothers suffering from post-natal illness. It exists to increase public awareness of the illness and to encourage research into its cause and nature.

Aware - Helping to defeat depression: Helpline: 1890 303 302. Provides information and support to people affected by depression in Ireland and Northern Ireland.

Depression Alliance: Tel: 0845 123 23 20; email: information@depressionalliance.org Information, support and understanding for people who suffer with depression, and for relatives who want to help. Self-help groups, information, and raising awareness for depression.

Depression UK: (Previously the Fellowship of Depressives Anonymous); Email:info@depressionuk.org. A national mutual support group for people suffering from depression.

MDF The Bipolar Organisation: Tel: 0207 931 6480; email; mdf@mdf.org.uk. A user-led charity working to enable people affected by bipolar disorder (manic depression) to take control of their lives.

National Association for Premenstrual Syndrome: Phone/Fax: 0844 815 7311. Medical charity providing information, advice and support to women affected by PMS, their partners and families.

Relate: Tel: 0300 100 1234; email: enquiries@relate.org.uk. UK's largest and most experienced relationship counselling organisation.

Samaritans: Helpline: 08457 90 90 90; (Ireland): 116 123; e-mail: jo@samaritans.org. National organisation offering support to those in distress who feel suicidal or despairing and need someone to talk to. The telephone number of your local branch can be found in the telephone directory.

SaneLine: Tel. 0300 304 700. A national out-of-hours telephone helpline offering emotional support and information for people affected by mental health problems. Open from 6pm to 11pm every day of the year.

Young Minds:Tel: 020 7089 5050. A national charity committed to improving the mental health of all children and young people under 25.