Download Special Report - Depression

Special Report - Depression
Depression is a common mental health disorder which affects over 120 million people worldwide.
However, most people are still not aware of the extent of this mental health issue, nor the treatments
that are currently available.
Improving such awareness, and providing mental health professionals with specific knowledge on the
topic, is what this Special Report is all about.
Historical Background (source: wikipedia)
The Ebers papyrus (c.a. 1550 BC) contains a short description of clinical depression. Though full of
incantations and foul applications meant to turn away disease-causing demons and other superstition,
it also evinces a long tradition of empirical practice and observation.
The modern idea of depression appears similar to the much older concept of melancholia. The name
melancholia derives from ‘black bile’, one of the ‘four humours’ postulated by Galen.
Clinical depression was originally considered to be a chemical imbalance in transmitters in the brain, a
theory based on observations made in the 1950s of the effects of reserpine and isoniazid in altering
monoamine neurotransmitter levels and affecting depressive symptoms. Since these suggestions,
many other causes for clinical depression have been proposed.
Awareness of Depression
In a survey conducted in October 2002 with 2,000 Australians aged over 18 years, depression and
general mental health problems were not included in the context of health. The surveyed were asked
about the major health problems in Australia, and the responses included coronary heart disease,
obesity and Cancer - but excluded depression. (Mathers, Vos, Stevenson 1999)
In the context of mental health, however, depression is perceived to be a major health problem.
Similar to suicide and schizophrenia statistics, most people fail to observe the extent of the problem
and are not aware of the number of people that suffer from depression. According to the World Health
Organisation (WHO), depression affects about 121 million people worldwide, being one of the leading
causes of disability worldwide.
In further posts we will discuss the prevalence of mood disorders; phenomenology of depression;
aetiology of depression; assessment of depression (including suicide assessment); and current
treatments and prevention strategies.
Mood Disorders - Facts and Figures
(Source: Black Dog Institute, 2007)
1. Mood disorders are overall more prevalent among men in the 35-44 age group, while for
women they are much more prevalent in the 18-24 age group. The lifetime risk of developing
depression is 12% for men and 25% for women.
2. Depression can be inherited. The genetic risk of developing clinical depression is about 40%
with the remaining 60% being due to factors in the individual’s own environment.
3. Depression is the fourth most common problem managed in general practice according to
data on general practice activity for 2004-05.
1
4. Women are more likely than men to experience mood disorders. Equal numbers of men and
women develop melancholic depression.
5. Suicide account for slightly more than one-quarter of all male deaths among the 20-24 age
group.
6. Between 1995-2005 in Australia, the rate of suicide among males was four time higher than
that of females.
7. The highest suicide rate for males in Australia in 2005 was observed in the 30-34 years age
group (27.5 per 100,000)
8. According to a World Health Organisation study, countries that reported the highest rates of
adults who experience a mental disorder during any 12-month period (prevalence) were USA
(26.4%); Australia (23.3%) and Ukraine (20.5%) in comparison to China (4.3%), Nigeria
(4.7%) and Italy (8.2%).
For more information, visit www.blackdoginstitute.org.au.
Phenomenology of Depression
The most prominent characteristic that all mood disorders share is a disturbance in mood (APA,
2000). For the mental health professionals these clients might be perceived frustrating to deal with
because about 70% of the clients who have had mood disorder can expect its reoccurrence
(Dziegielewski, 2002).
Depression is a mood state that is characterised by significantly lowered mood and a loss of interest
or pleasure in activities that are normally enjoyable. Depression is often difficult to diagnose because
it can manifest in so many different ways. This disorder encompasses body, feelings, thoughts and
behaviour to varying degrees. Symptoms can cause a significant personality change; ability to love
and work is grossly impaired by the depression and it makes difficult for others to empathise with the
depressed person.
Depressed mood is a common and normal experience in the population. However, a MAJOR
DEPRESSIVE EPISODE can be distinguished from this “normal” depression by its severity,
persistence, duration and the presence of characteristic symptoms. The most common emotional,
behavioural and physical symptoms of a major depressive episode are:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
Markedly depressed mood
Loss of interest or enjoyment
Reduced self-esteem and self-confidence
Feelings of guilt and worthlessness
Bleak and pessimistic views of the future
Ideas or acts of self-harm and suicide
Disturbed sleep
Disturbed appetite
Decreased libido
Reduced energy leading to fatigue and diminished activity
Reduced concentration and attention
Source: (WHO Collaborating Centre for Mental Health and Substance Abuse, 2000).
According to The International Classification of Diseases and Related Health Problems ICD-10 (WHO,
2007), major depression can be coded according to:
Severity – mild, moderate, severe
2
In mild depression, an individual have some symptoms and is usually associate with only minor
impairment in work and social functioning. Moderate depression already involves impairment in
occupational and social functioning and severe depression may include psychotic symptoms as well.
Somatic features are present in most cases.
Psychotic Features – hallucination, delusions
Psychotic features are usually present in only severe form of depression and most prominent features
are hallucinations and delusions. Hallucinations are distorted perception and sensation (i.e. seeing,
hearing, smelling) and delusions are distorted thoughts (i.e. false beliefs that are firmly held despite
objective and contradictory evidence). Usually they involve mood congruent themes of guilt,
punishment, impending disaster and bodily illnesses.
Somatic Features
Most prominent somatic features include marked loss of interest or pleasure in activities that are
normally pleasurable, lack of emotional reaction, waking in the morning 2 hours or more before the
usual time, marked psychomotor retardation or agitation, marked loss of appetite, weight loss and
marked loss of libido
The average duration of an untreated episode is 12 weeks (sometimes only 4-6 weeks).
Approximately 10% of people never recover without treatment. With an appropriate treatment, the
majority of individuals will experience a complete recovery from the current episode. However, some
individuals will require more lengthy and intensive treatment.
The term ‘treatment resistant depression’ (WHO Collaborating Centre for Mental Health and
Substance Abuse, 2000) has sometimes been used to define depression that does not respond well
to medical treatment such as medication and ECT (Electro Convulsive Therapy).
This term has been criticised as being a pure labelling phenomenon. It does not take into account that
individual’s depression and symptoms should be matched with the treatment and that psychosocial
factors influence maintenance of depression. It does even not include whether or not the client has
received an adequate course of psychotherapy or counselling.
Quick Reference to Depression
(Source: APA, 2000)
Depression disorders: These disorders have the presence of one or more depressive episodes
without history of manic or hypomanic episodes.
Major depressive disorder: This disorder is characterised by one or more major depressive episodes
that must last at least two weeks.
Dysthymia: This disorder is characterised by a two-year history of depressed mood, and the individual
must not be without symptoms for two months. This disorder is considered less severe than the
symptoms noted in major depressive disorder.
Depressive disorder NOS (Not Otherwise Specified): This disorder is similar to the other NOS
categories as individuals in this area do not meet the full criteria for one of the other mood disorders
listed above.
Aetiology of Depression
Equifinality (Barlow, & Durand, 2005) is a term that describes the same end product resulting from
possibly different causes. Just as there may be many reasons for headache, there may also be a
variety of reasons for depression. Leading contemporary psychologists agree that aetiology of
3
depression could not possibly be explained by only one set of factors, being it biological,
psychological or social, whatever the precipitating factor.
Biological aetiological factors involve genetic, neurochemical and hormonal factors.
Studies that allow estimation of genetic contribution are family studies and twins studies. Family
studies show that the rate in first degree relatives of individuals with mood disorder is consistently
about two to three times greater than in families without depressed members. Similarly, twin studies
show that concordance rate in co-occurrence of depression is far greater within identical twins
population than is within fraternal twins (McGuffin, Rijsdijk, Andrew, Sham, Katz, & Cardno, 2003).
Research on abnormal brain functions associated with depression has focused on deficient
availability of a class of neurotransmitters known as dopamine and serotonin (Hansell, & Damour,
2005). The hormonal system in the body may also play an important role in some forms of
depression. For a long time, clinicians have known that endocrine disorders such as hyperthyroidism
or hypothyroidism can cause depression.
Psychological aetiological factors contribute to the development of depression in 60 to 80% of cases
(Barlow, & Durand, 2005). Furthermore, most of these psychological experiences are unique to the
individual. Main factors could be allocated into three clusters – stressful life events, learned
helplessness and negative cognitive styles.
Stress and trauma are among the most striking factors in developing of all psychological disorders.
This is reflected in wide adoption of the diathesis-stress aetiological model that describes genetic
predisposition and psychological vulnerability. Predisposition (diathesis) is triggered by stressful event
and might lead to depression. Reaction to stressful event or trauma is an individual response.
It means that not all persons exposed to the same stress will develop psychological disorders. It is
called multiple causality. Having a particular vulnerability does not mean that a person will develop an
associated disorder. The smaller the vulnerability, the greater stress is required and conversely, the
greater the vulnerability, the less stress is required. This model of nature – nurture interaction has
been very popular, although here presented in a simplified form.
Seligman (1975) presented interesting research findings with animals. Dogs and rats have an
emotional reaction to events over which they do not have control. Animals learn that nothing they do
helps them avoid a shock (from experiment) and soon they become very helpless, give up and display
animals’ equivalent of depression. Seligman suggested that humans behave similarly – they tend to
decide that they have no control over the stress in their life and become depressed. These findings
evolved into an important model called the learned helplessness theory of depression (Barlow, &
Durand, 2005).
Aaron Beck (1967) suggested that the depression may result from a tendency of persons to interpret
everyday events in a negative way and he called it the negative cognitive style. People with
depression make the worst of everything and make cognitive errors about themselves, world around
them and their future. Beck called it depressive cognitive triad.
Most prominent social aetiological factors in developing depression are marital relationship, gender
and social support. World data on depression shows a dramatic gender imbalance where almost 70%
of individuals with depression are woman.
Diagram 1 - Lifetime international rate per 100 people for major depression (Source: Barlow, D.H., &
Durand, V.M. (2005). Abnormal psychology: An integrative approach. Belmont, CA: Thomson
Wadsworth)
4
As presented in the image below, an integrative model of depression’s aetiology would necessary
take into account all factors that contribute to the development of depression. The interplay between
biological and psychological vulnerability, and presence of stressful life events could activate stress
hormones; create sense of hopelessness and cognitive distortions. It may be the base for problems in
social and intimate relationships and this process often leads to depression.
Diagram 2 - An Integrative Model of Mood Disorders (Adapted from: Barlow, D.H., & Durand, V.M.
(2005). Abnormal psychology: An integrative approach. Belmont, CA: Thomson Wadsworth)
Assessment of Depression
Depression is a psychological disorder that involves all functions of an individual’s existence. It affects
the way a person behaves, thinks and feels. Depression is not merely a passing “blue mood”. People
who have depression could not simply get over it and get better. Without treatment, usually
medication, symptoms last for weeks, months, even years.
5
Usually the first step in getting appropriate treatment is a physical examination by the medical doctor
and later a thorough psychiatric assessment. A good evaluation will include Psychiatric Assessment
with Suicide Risk Assessment (more on suicide in Chapter VI), Mental State Examination, Symptoms
Checklist, DASS (Depression Anxiety Stress Scale) and BDI (Beck Depression Inventory).
The Psychiatric Assessment (done by medical professionals) is a standard component of
assessments for all mental disorders (WHO Collaborating Centre for Mental Health and Substance
Abuse, 2000).
The aim of this assessment is to identify diagnosis and other existing problems, assess suicide risk,
highlight areas that require intervention so that goals can be set and management plan devised, and
identify the baseline against which improvement or deterioration can be measured. Questions are
devised to obtain information needed to help mental health teams appropriately match client with
treatment.
Data is collated from answers to following enquiries:
1.
2.
3.
4.
5.
6.
7.
Identify the presenting problem
History of the present problem
Personal history
Previous medical history
Drug history
Pre-morbid personality (what was the person like before the problems)
Family history
The Mental State Examination (MSE) is also done by health professionals. It includes an
assessment of the current or actual state of the client. The MSE is designed to obtain specific aspects
of the individual’s mental experiences and behaviour at the time of interview. Sometimes it is not
possible to organise immediate assessment with a specialist.
Other mental health workers with more basic knowledge should also be able to assess mental state
and to use the same professional terminology in order to devise the best management plan. The MSE
should be also used routinely with clients who might experience relapse. Following aspect of client’s
experiences and behaviours are assessed.
1.
2.
3.
4.
5.
6.
7.
8.
Appearance and behaviour
Speech
Mood and affect
Form of thought
Content of thought
Perception
Sensorium and cognition
Insight
Symptoms Checklist
Symptoms of depression could be grouped into three clusters – physical, cognitive and behavioural.
Each symptom cluster requires emphasis on different treatment options. This checklist may be helpful
if used regularly throughout treatment.
Here are some of examples of the checklist (WHO Collaborating Centre for Mental Health and
Substance Abuse, 2000):
1. Physical symptoms – sleep disturbance; appetite disturbance, weight change, loss of energy
etc.
2. Cognitive symptoms – excessive self-criticism or guilt, feelings of hopelessness, suicidal
thoughts, decreased pleasure etc.
6
3. Behavioural symptoms – loss of motivation, apathy, impaired ability to make decision,
difficulty setting goals etc.
DASS (Depression Anxiety Stress Scale) and BDI (Beck Depression Inventory).
“The DASS (Depression Anxiety Stress Scale) is a 42-item self report instrument designed to
measure the three related negative emotional states of depression, anxiety and tension/stress. The
DASS questionnaire is in the public domain and may be downloaded from the University of New
South Wales website.
(There are no restrictions or copyright issues imposed on use).
“The DASS was constructed to further the process of defining, understanding and measuring the
clinically significant emotional states usually described as depression, anxiety and stress. The DASS
should thus meet the requirements of both researchers and scientist-professional clinicians” (quoted
from Psychology Foundation of Australia, 2007).Each of the three scales (depression, anxiety and
stress) contains 14 items, divided into subscales of 2-5 items with similar content.
The Depression scale assesses dysphoria, hopelessness, devaluation of life, self-deprecation, and
lack of interest/involvement, anhedonia, and inertia. The Anxiety scale assesses autonomic arousal,
skeletal muscle effects, situational anxiety, and subjective experience of anxious affect. The Stress
scale is sensitive to levels of chronic non-specific arousal. It assesses difficulty relaxing, nervous
arousal, and being easily upset/agitated, irritable/over-reactive and impatient.
Subjects are asked to use 4-point severity/frequency scales (from 0 to 3) to rate the extent to which
they have experienced each state over the past week. Scores for Depression, Anxiety and Stress are
calculated by summing the scores for the relevant items.” (quoted from Psychology Foundation of
Australia, 2007).
Characteristics of high scorers on each DASS scale (quoted from Psychology Foundation of Australia,
2007):
1. Depression scale
1. self-disparaging
2. dispirited, gloomy, blue
3. convinced that life has no meaning or value
4. pessimistic about the future
5. unable to experience enjoyment or satisfaction
6. unable to become interested or involved
7. slow, lacking in initiative
7
2. Anxiety scale
1. apprehensive, panicky
2. trembly, shaky
3. aware of dryness of the mouth, breathing difficulties, pounding of the heart,
sweatiness of the palms
4. worried about performance and possible loss of control
3. Stress scale
1. over-aroused, tense
2. unable to relax
3. touchy, easily upset
4. irritable
5. easily startled
6. nervy, jumpy, fidgety
7. intolerant of interruption or delay”
For more information on the DASS and how to administer it, please refer to above mentioned website.
Beck Depression Inventory is copyrighted by the Psychological Corporation. Material here
presented is only for educational purpose because the BDI should be used only by registered
professionals. The original version of the BDI was introduced by Beck, Ward, Mendelson, Mock and
Erbaugh in 1961 (cited in Victims’ Web, 2007). The BDI was revised in 1971 and made copyright in
1978.
The BDI is a 21 item self-report rating inventory measuring characteristic attitudes and symptoms of
depression. Each item represents one attitude, such as sadness, pessimism, sense of failure,
dissatisfaction, guilt, expectation of punishment, dislike of self, self accusation, suicidal ideation,
episodes of crying, irritability, social withdrawal, indecisiveness, change in body image, retardation,
insomnia, fatigability, loss of appetite, loss of weight, somatic preoccupation and low level of energy.
The highest score on each of the twenty-one questions is three (3), the highest possible total for the
whole test is sixty-three (63). The lowest possible score for the whole test is zero. The total is
obtained when the scores are added for all of the twenty-one questions.
Levels of Depression according to the BDI:
•
•
•
•
05 - 09 Healthy score
10 - 18 Mild to moderate depression
19 - 29 Moderate to severe depression
30 - 63 Severe depression
Samples item of the BDI questions:
Item 7 – Dislike of self
•
•
•
•
0 I don’t feel disappointed in myself.
1 I am disappointed in myself.
2 I am disgusted with myself.
3 I hate myself.
8
Suicide Assessment
(Source: www.med.umich.edu/depression/suicide_assessment)
Many people will experience the suicide ideation at some points in their life, although people who are
diagnosed with depression (and bipolar disorder, too) are more likely to commit suicide than
individuals with any other diagnosable psychological disorder. The rate of death from suicide within
the population diagnosed with depression ranges from 9 to 60% (WHO Collaborating Centre for
Mental Health and Substance Abuse, 2000).
The role of the community mental health workers in suicide management is twofold. Firstly, they need
to be able to handle actual suicide attempt and secondly they need to be able to recognise and act on
suicide ideation. It is important for the professional to be non-threatening, non-judgmental and
empathetic when talking to the suicidal client.
Listed below are some useful questions to ask the client who has suicidal thoughts:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
Have you been feeling depressed for several days at a time?
When you feel this way, have you ever had thoughts of killing yourself?
What did you think you might do to yourself?
Did you act on these thoughts in any way?
When was the last time you had these thoughts?
Have your thoughts ever included harming someone else?
Have you taken any steps towards doing this? Have you thought when and where you would
do this?
Have you made a note?
What has stopped you from acting on your thoughts so far?
What are your thoughts about staying alive?
How does talking about suicide make you feel?
(Adapted from: Fremouw, W.J., de Perczel, M., Ellis, T.E. (1990). Suicide risk: Assessment and
response guidelines. New York: Pergamon Press)
9
When working with a client who is contemplating suicide or recovering from the attempt, it is important
to develop a management plan to help an individual safely move out from distressed state. The
suggestions for this management plan are outlined below:
1.
2.
3.
4.
5.
6.
7.
Ensure appropriate supervision and/or hospitalisation for the client
Ensure that the client has immediate 24 hour access to a mental health service
Remove all means of committing suicide
Build a therapeutic relationship with the client
Try to delay the client’s suicidal impulses (e.g. make a contract)
Neutralise the precipitating problem
Involve family members or supportive family network
(Adapted from: WHO Collaborating Centre for Mental Health and Substance Abuse, 2000)
Predictors of Suicide Risk
Sex – women attempt suicide more often, but men complete suicide more often. Significant
others – meaning of intimate relationships. Stressful life events – such as loss of a loved one,
financial strains.
Unsuccessful attempts – make it more likely that a future attempt will be successful.
Unemployment – or being retired increase a risk of suicide. Unexplained improvement – in
clinical sense may indicate a resolution.
Identification – with others who have committed suicide.
Chronic Illness – depression is also associated with higher risk.
Depression – hopelessness, frustration and hostility are associated with greater risk. Decision
– that suicide in future is an option.
Age – generally, the older the individual, the greater the risk. Alcohol – or other substance
abuse is often associated with completed suicide. Availability – of weapons, especially guns
represent higher risk.
Lethality – of previous attempts.
(Adapted from WHO Collaborating Centre for Mental Health and Substance Abuse, 2000)
Treatment for Depression
The essential features of treating clients with depression relate to physical treatment, psychotherapy,
education and support for the individual and the family, reduce of residual problems – structured
problem solving; improving sleep; increasing activity; encouraging “normal” eating behaviours;
relaxation training; assertiveness and clear communication and prevention of relapse or recurrence of
depression.
Treatment options are clearer after a thorough assessment has been completed. There are a variety
of antidepressant medications, various psychotherapeutic and counselling approaches and usually a
combination of treatments will bring the most benefits to the individual. It is outside of this course’s
scope to discuss medical treatments such as use of medication or administration of the still
controversial ECT.
Psychotherapy and counselling are useful treatment options for clients with depression, even if it is
combined with use of medication. This kind of treatment may be useful if the client has had a prior
positive response to counselling, a competent and trained counsellor is available and the client
prefers psychological treatment. All counselling approaches with proven effectiveness tend to be time
10
limited, focused on current problems and aimed at symptom reduction rather than personality change
(WHO Collaborating Centre for Mental Health and Substance Abuse, 2000).
In 1991, Gorey and Cryns (as cited in Brown, & Lent, 2000) conducted a meta analysis of group
therapy with clients who have depression and concluded that small groups with less than six
members were more effective. They concluded also that brief group interventions are more effective
than long-term group interventions with the population who have depression.
There are several different types of counselling modalities of choice such as cognitive therapy, peer
support group therapy, family therapy and family support group therapy that are usually considered
when working with clients who have depression (Dziegielewski, 2002).
Thyer and Wodarski (1998) listed useful strategies for each therapy of choice:
Counselling Strategies for Cognitive Therapy
1. Look for cognitive distortions that influence the development and maintenance of mood
disorders.
2. Discuss negative distortions related to expectations of the environment, self and future that
contributes to depression.
3. Examine the client’s perceptions of environment and activities that are seen as unsatisfying or
unrealistic.
4. Identify dysfunctional patterns of thoughts and behaviour and guide the client to evidence and
logic that test the validity of the dysfunctional thinking.
5. Assist in understanding automatic thoughts that occur spontaneously and contribute to the
distorted affect. If this technique works, help the client to explore other possibilities.
6. Help the client use “I” statements in identifying feelings and reactions.
Counselling Strategies for Peer Support Group Therapy
1. Provide the client with a feeling of security when discussing troublesome or embarrassing
issues. This group will also help the client in discussing medication-related issues and serve
as a forum for promoting depression-related education.
2. Help the client gain a sense of perspective on his or her condition and encourage him or her
to link up with others who have common or similar problem.
3. Convey a sense of hope when the client is able to see that he or she is not alone or unique in
experiencing depression.
Counselling Strategies for Family Therapy for Depression
1. Work with families to formulate a therapeutic plan to resolve symptoms and restore or create
adaptive family functions.
2. Build an alliance with the client and their family members.
3. Combine psychotherapeutic and medical treatment education.
4. Obtain each family member’s view of the situation and specify problems, clarify each
individual’s needs and desires using each individual’s preferred vocabulary and accept his or
her perceptions at this time.
5. Be non-blaming and accepting of the client and the family.
11
6. Assure the family members that they did not cause the depression.
7. Allow the family members to ventilate about the chronic burden they have experienced.
8. Examine any objective and subjective burdens the family is experiencing due to observable
aspects of depression and the need to provide care giving.
9. Look for criticism or emotional over involvement of family members in response to the client’s
depression.
10. Help to redefine the nature of the family’s difficulties.
11. Encourage recognition of each family member’s contribution to the discord.
12. Recognise and modify communication patterns, rules and interaction patterns.
13. Increase reciprocity through mutual exchange of privileges.
14. Decrease the use of coercion and blaming.
15. Increase cooperative problem solving.
16. Increase each member’s ability to express feelings clearly and directly, and to hear others
accurately.
Counselling Strategies for Family Support Group Therapy
1. Provide therapeutic benefits and support for the family.
2. Enhance knowledge in complying with the medication regimen.
3. Provide the family members with a feeling of security when discussing troublesome or
embarrassing issues.
4. Help the family members in discussing medication-related issues and serve as an avenue for
promoting education related to depression and its treatment.
5. Help the family members gain a sense of perspective on their condition and tangibly
encourage the family members to link up with others who have common or similar problem.
6. Convey a sense of hope where the family members are able to see that they are not alone or
unique in experiencing depression.
Copyrights © Counselling Academy
12