Beating Depression

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					    PANORAMA PSYCHIATRY & MEMORY CLINIC




BEATING DEPRESSION
How To Improve Your                                                                    Overview
Chances of Recovery                                                                 This handout provides
                                                                               information on depression.
                                                                               It starts off by explaining
from Depression                                                                the difference between
                                                                               normal unhappiness and the
Learn more about depression and the treatments that are                        illness of sadness that is
available...                                                                   called depression.
                                                                                   The symptoms of
         All of us experience hap-                                             depression are described.
piness and sadness on a daily ba-                                              Anxiety often occurs in
sis. This natural variation in mood                                            depression and it is also
is not the same as a disease condi-                                            explained.
tions, such as depression, that af-                                               Depression changes the
fect the emotional functions of the
                                                                               way the brain works and
brain. Depression causes changes
in the biochemistry and structure                                              affects the levels of certain
of the brain and it is therefore ac-                                           chemicals as well as the
knowledged as a true medical ill-                                              binding of these chemicals.
ness.                                                                              Depression is common
                                                                               and occurs in approximately
An example of normal day-to-day         form of self-help to get us out of     1 out of 5 women and in 1
happiness and unhappiness is the        our little black hole.                 out of 10 men.
feelings that we experience when
we watch our favourite sport on a       DEPRESSION IS DIFFERENT                    Seeking treatment early
Saturday. If our team does particu-     In contrast, the sad, heavy, empty     helps to limit the impact of
larly well and beats the opposition,    feeling of depression is something     the illness. Antidepressants
then it lifts our spirits and we feel   that we have little control over. We   and talk therapy are the best
high and happy. Our interaction         may be able to feel better for a       treatments for depression.
with family members is positive         while after we’ve had our braai,
and we have an optimistic view of                                                  Talking about your
                                        but soon afterwards the blackness
the present and future. However, if                                            thoughts, especially worries,
                                        sets in again. No matter what we
our team plays particularly poorly      do, we just seem to be unable to       helps to relieve the pain of
and loses then we become negative       pull ourselves out of the depths of    depression.
and moody. This also has an effect      despair. This lack of control over
on our family and more often than       the sadness of real depression is
not we may find that family mem-        the first distinguishing feature be-
bers retreat to allow us to get over    tween depression and normal un-
our moodiness. We may also ad-          happiness. The second distinguish-
minister self-treatment in the form     ing feature is that depression feels
of a braai and perhaps also drink       very different. Depression is de-
alcohol. The result is that we feel     scribed as an uncomfortable and
better and soon we are able to tell     unpleasant feeling associated with
ourselves that our team will per-       deep sadness. Normal day-to-day
form better next week, or that the      unhappiness feels sad, but does not
opposition played really well and       have that uncomfortable quality of
deserved to win. Ultimately, how-       depression.
ever, we can make use of some


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    PANORAMA PSYCHIATRY & MEMORY CLINIC



THE CORE FEATURES OF                     4. Suicidal thoughts. You have           may not stand out at these activi-
REAL DEPRESSION                              feelings that life is not worth it   ties.
The two central features of depres-          and that things will be better if
sion are sadness and a lack of en-           you are not here anymore.            However, sometimes we experi-
joyment. One or both of these fun-       5. Sleep changes. Most people            ence excessive anxiety that is bad
damental features must be present            have difficulty sleeping at          for us and this often occurs to-
in order to diagnose depression.             night. Others sleep more than        gether with depression. Too much
The sadness is a sad, heavy and              usual as they tend to sleep dur-     anxiety is characterised by three
empty feeling that is present al-            ing the day to forget and to         important symptoms:
most every day, for a large part of          switch off.
the day, and lasts for 2 weeks or        6. Appetite changes. Most peo-           1. Tension. People with exces-
longer. Lack of enjoyment con-               ple experience a decrease in            sive anxiety report that they
sists of an inability to find pleasure       appetite while others tend to           have a feeling of tenseness in
in or enjoy things that you previ-           eat more.                               their chest.     It feels like a
ously were able to enjoy. This lack      7. Poor concentration.           You        tightness or knot. They also
of enjoyment is also present almost          struggle to focus and to con-           report an inability to relax or
every day, for a large part of the           centrate on work and events.            to feel at ease and calm.
day, for 2 weeks or longer.                  This leads to impaired mem-          2. Excessive worry. Too much
                                             ory.                                    anxiety causes the brain to
                                         8. Poor energy. You may not                 manufacture worries. People
DEPRESSION AND YOUR                          have energy to work or per-             with excessive worrying worry
BRAIN                                        form duties as before. Some             where there really is no reason
Depression changes the way the               people report that they have            for concern. They tend to think
brain works. The accompanying                lead in their legs and can’t get        a lot about little insignificant
sketch indicates a side view of the          going.                                  difficulties. For example, they
brain. At the base of the brain are      9. Changes in movements. Oth-               suddenly start to worry exces-
two areas called the Locus Co-               ers around you may observe              sively about being on time or
eruleus (LC) and Raphe Nucleus               that you have become restless           they worry excessively that
(RN). These two areas regulate,              and move around a lot. You              people may not like them.
amongst other things, the feelings           may struggle to sit still. In        3. Bodily symptoms.          People
of happiness or sadness and anxi-            contrast, some of us with de-           with anxiety experience head-
ety. The LC/RN does this by send-            pression may move slower and            aches, tightness in the chest,
ing out messages to many different           tend to do things slower than           breathing difficulties, heart
parts of the brain and so communi-           before.                                 palpitations, excessive sweat-
cates states of feeling.                 10. Pains and aches. Many people            ing, shakiness, uncomfortable
                                             with depression report that             feelings in their stomach, mus-
                                             they have more bodily aches             cle aches and pains, clenching
                                             and pains. Muscles and joints           of teeth, urinating excessively
                                             may also pain. You may also             and feelings of chills or fevers.
                                             experience more headaches
                                             than before.                         A CLOSER LOOK AT BRAIN
                                         11. Sexual function. Most people         CHANGES WITH DEPRES-
                                             report that they are not inter-      SION
                                             ested in sex and that the fre-       This diagram shows two brain
                                             quency of their sexual behav-        cells connecting in the LC/RN
A change in function of the LC/RN            iour has decreased. In some          area.
area results in depression or anxi-          instances people may report
ety.                                         that they have an increase in
                                             sexual behaviour.
THE CHARACTERISTICS OF
DEPRESSION                          DEPRESSION & ANXIETY
                                    Depression is often accompanied
1. Sadness.                         by unbearable anxiety. For most of
2. Lack of enjoyment.               us, anxiety is a natural part of our
3. Poor self-image. You view existence. It helps to feel anxious
   yourself in a negative light and about exams and going to work to The connection area between two
   tend to put yourself down.       earn money. If we don’t then we brain cells is called a synapse.


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    PANORAMA PSYCHIATRY & MEMORY CLINIC



Brain cells (also called neurones)       and serotonin in the synapse. The      Antidepressants target depression
talk to each other through two           cell that receives the messages in a   by working at the LC/RN site of
mechanisms; one is a process that        synapse responds to an excess of       the brain. They increase the con-
is very similar to electricity and the   neurotransmitters by “swallowing”      centration of noradrenaline and
other is a chemical process. The         the extra binding sites. This proc-    serotonin in the synapse almost
electricity moves down the neu-          ess heralds the recovery of depres-    immediately after you have taken
rone on the left and when it             sion and the system then returns to    your first tablet. However, you do
reaches the end of the cell, it          how it was before the onset of de-     not immediately feel better after
causes a little bladder to release       pression.                              starting on antidepressants. Most
chemicals. The chemicals then                                                   people notice an improvement
cross the space (synapse) and bind                                              within the first few weeks, al-
to a specific area on the next cell                                             though most report that they feel
called a receptor. Once it binds to                                             their old selves again only after a
this area it stimulates the neurone                                             few months of treatment. It takes a
on the right to generate electricity.                                           few months before the number of
The electricity then continues                                                  receptors decrease significantly
down the body of the cell. The                                                  and this is associated with what
chemicals that allow the electrical      Other parts of the brain such as the   can be called a cure. In the begin-
impulse to cross the synapse and         frontal lobes are involved in the      ning of treatment the rapid in-
thus propagate the electrical im-        thinking processes that accompany      crease in the concentration of
pulse from one cell to the other are     depression. Negative self-talk and     noradrenaline and serotonin can
called neurotransmitters. In de-         thoughts of putting yourself down      sometimes lead to side effects such
pression the neurotransmitters be-       characteristically occur in depres-    as restlessness and agitation.
come deficient and this causes the       sion.    Patients have given the
symptoms of depression. Specifi-         name; “washing machine                 HOW COMMON IS DEPRES-
cally we get a decrease in the con-      thoughts” to these types of            SION?
centration of noradrenaline and          thoughts. If you put dirty clothes     Depression is a common illness. It
serotonin. This decrease causes an       into an automatic washing machine      occurs in approximately 1 out of 5
increased production of receptors        and start the washing cycle then       women. The incidence is a little bit
on the cell that receives the chemi-     you are able to view through the       lower in men where it occurs in
cal message (up-regulation).             window dirty washing going             about 1 in 10 men.
                                         around and around in dirty water.
Thus, in depression, your brain has      Similarly, these negative thoughts     IS TREATMENT NECES-
a deficiency of noradrenaline and        of depression keep on turning in       SARY?
serotonin, and an increased num-         your mind and it leaves no space       It is important to distinguish de-
ber of binding sites or receptors.       for optimistic or positive thinking.   pression from normal unhappiness
                                         Most happy people tend to think        which is a part of life, as it is un-
                                         about happy events that have oc-       necessary to treat normal unhappi-
                                         curred or perhaps they look for-       ness. We provided distinguishing
                                         ward to happy events in the future     features above in the introduction.
                                         such as birthdays, anniversaries or    It is important to treat depression
                                         even a holiday. Washing machine        when it interferes with your ability
                                         thoughts may project back to the       to function optimally at home and
                                         LC/RN to worsen the abnormali-         at work. If it affects your quality
                                         ties that have been described          of life and makes you unable to
Neurotransmitters are usually ab-        above. Psychotherapy works on          enjoy life, treatment will help you
sorbed back into the cell that re-       these washing machine thoughts to      to feel better and to enjoy life
leases them. This re-absorption          improve your thinking.                 again.
process can be blocked by certain
medications. Antidepressants can                                                In many instances depression is a
either block the re-uptake of sero-                                             self-limiting condition. It usually
tonin or of noradrenalin, or in                                                 takes 9 to 12 months for depres-
some instances the antidepressant                                               sion to improve on its own. More
will block the re-uptake of both.                                               severe forms of depression will not
Blocking the re-uptake of neuro-                                                improve and may even lead to
transmitters causes an increase in                                              death through suicide or starvation
the concentration of noradrenaline


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    PANORAMA PSYCHIATRY & MEMORY CLINIC



and general deterioration of bodily     person drives his car down the         rejected, which worsens their de-
functions. In the era before anti-      road and approaches a traffic light    pression.
depressants most people had to          which turns red. The person thinks
endure the illness and wait for it to   nothing of this and stops his car.     A melancholic depression is a par-
subside. In today’s modern society      On the other hand, somebody with       ticularly severe form of depression
we don’t have the time to wait for      depression may think that even the     where patients report a significant
depression to get better. Depres-       red traffic light is against him/her   worsening of their depressive
sion interferes with your ability to    and that like everything in life,      symptoms in the morning. The
earn an income and look after           nothing is working out well today.     symptoms usually improve during
yourself and your family. It is         This is perhaps the final straw that   the course of the day.
usually not worth it to wait for an     confirms that he/she is a failure
extended period until you get bet-      and that sadness is a way of life.     Postpartum depression is a type of
ter. In the end most patients agree     Even though this is an extreme         depression that develops in women
that it is more sensible to get         example, it illustrates the effect     after giving birth. This is not the
treatment so that you can carry on      that depression can have on your       same as the “blues” that occur in
with your life.                         thinking.                              the first week after giving birth.
                                                                               Postpartum depression is a particu-
WHAT CAUSES DEPRES-                     Some medical illnesses cause de-       larly severe depression that occurs
SION?                                   pression. A decreased production       within the first 3 months after giv-
There is a strong genetic compo-        of thyroid hormone (hypothyroid-       ing birth. It can sometimes be so
nent for the development of de-         ism) is often accompanied by de-       severe that the mother may have
pression. Depression occurs more        pression. Metabolism of the neu-       thoughts of harming her baby or
commonly in certain families and a      rones slow down and the result is      herself. This is a medical emer-
positive family history predisposes     the symptoms of depression.            gency and should be reported to
you to the development of depres-       Other illnesses that are associated    your doctor immediately.
sion.                                   with depression are strokes, head
                                        injuries and dementia. Substance      The last type of depression that is
Relationship difficulties, financial    abuse and dependence are also as-     often described is called a cata-
stress and chronic illness are          sociated with depression. Alcohol     tonic depression. This type of de-
common factors associated with          suppresses brain functioning and      pression is characterised by a vir-
the development of depression.          prolonged use often results in de-    tual sensation of all movement.
However, these stress factors are       pression.                             Patients are immobile, refuse to
part of life and cannot always be                                             move and also refuse to take in any
held accountable for the develop-       TYPES OF DEPRESSION                   fluids or food. This is also a medi-
ment of depression.      See below      The most common type of depres- cal emergency and these patients
for more information on this. It is     sion is the one where people report may require special care in order to
also possible that stress from          sadness and a lack of interest in improve.
childhood may result in the devel-      enjoyable activities. This is called
opment of depression in later life.     a major depressive disorder.          Depression may also occur as part
                                                                              of a bipolar disorder. In bipolar
Stress from our surroundings is an      An atypical depression is another disorder patients experience the
easy scapegoat for causing depres-      type that is associated with pro- two extreme poles of emotions
sion, but the situation is often more   nounced feelings of a lack of en- namely depression and mania.
complex. Some people experience         joyment, increased sleep, increased Mania is a condition of euphoria
normal life stress and go on to de-     appetite and profound loss of en- accompanied by racing thoughts,
velop depression. They then, be-        ergy. Patients describe this lack of increased energy and decrease
cause of the depression, interpret      energy as typically a leaden or need for sleep.
normal life stress as especially        heavy feeling in their legs. Atypi-
stressful and this may even trap an     cal depression is also accompanied TREATMENT
inexperienced therapist to focus on     by a heightened (sensitivity to be- Depression can be treated with
the stress rather than the depres-      ing rejected in relationships) sense psychotherapy, medication or other
sion. Therefore, you should not         of rejection sensitivity in relation- forms of therapy such as electro-
only focus on events around you         ships. Patients report that they convulsive therapy.
that upset you but also understand      require constant reassurance that
that depression causes you to in-       relationships are working out well Psychotherapy involves talking
terpret normal things as stressful.     and if they don’t get this they feel and usually occurs between a pa-
Consider the following example: A                                             tient and a trained therapist. The


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    PANORAMA PSYCHIATRY & MEMORY CLINIC



therapist will analyse the thinking    synapse. An example of this class
patterns of the patient and point      of drug is Wellbutrin.                            Sometimes we are not fully aware
out thinking that worsens depres-                                                        of the impact that depression has
sion. Through this process the pa-     Receptor blockers                                 on our way of living. We feel the
tient will also gain insight and un-   Some medications block binding pain, but also try to press on with-
derstanding about him/herself and      sites on the cells that release out getting treatment. Be aware
how he or she relates to people        chemicals. This results in an in- that depression affects your brain’s
around them. Cognitive behav-          crease of serotonin and noradrena- ability to correctly interpret the
ioural therapy (CBT) and interper-     line in the synapse. Examples in- influence that depression has on
sonal psychotherapy (IPT) are the      clude Remeron and Molipaxin.                      your life. The impact may be far
two types of therapy that have the                                                       greater than you are aware of and
best results in depression. These      Electroconvulsive therapy                         you should find help for your own
therapies have been well re-           Electroconvulsive treatment (ECT) sake and also for those around you.
searched and have proven to be as      is also called “shock therapy”. If you are in doubt then rather go
beneficial as medication in mild to    This type of treatment is usually for an assessment. The doctor who
moderate depression. CBT works         only used in instances of more se- examines your brain for the symp-
by helping patients to identify and    v e r e d e p r e s s i o n , t r e a t m e n t - toms of depression will be more
correct negative thought patterns      resistant depression, or where the objective as he is not trapped in-
and beliefs. IPT helps the patient     person cannot participate in other side your mind.
to understand depression and how       treatments due to, for example,
it is worsened by interpersonal        pregnancy or major illness. ECT is WHO TREATS DEPRES-
conflict.                              administered in an operating thea- SION?
                                       tre under general anaesthetic and a A number of professionals are in-
Numerous research studies have         muscle relaxant is also given. volved in the treatment of depres-
shown that the combination of          During the procedure a small elec- sion. Often your general practitio-
psychotherapy and medication is        trical current is administered to the ner is the point of first contact.
the best treatment available today.    brain. In most instances the de- Your GP may be the one who made
These two treatments work on dif-      pression recovers quickly with this the diagnosis and started initial
ferent aspects of brain functioning,   treatment.                                        treatment.     If you respond to
as described above, and the com-                                                         treatment then often no further in-
bination probably gives you the        IMPACT OF DEPRESSION                              tervention is required. In cases of
best chance of not suffering from a    Depression has a tremendous im- a non-response or troublesome side
relapse.                               pact on family and work life. It effects your GP may refer you to a
                                       affects all your relationships at specialist such as a psychiatrist. A
ANTIDEPRESSANTS                        home and it is important to be psychiatrist is a medical practitio-
SSRI                                   aware of this so that you can limit ner who received a further four
Selective Serotonin Re-uptake In-      the impact. You may feel with- years of training in working with
hibitors work by blocking the re-      drawn and less interested in recrea- depression and other mental condi-
uptake of serotonin. The result is     tional activities. Your significant tions. Your psychiatrist may order
high levels of serotonin in the syn-   others may interpret this as rejec- blood tests or brain scans to exam-
apse. Examples of these kinds of       tion and feel that you dislike them. ine further for other causes of de-
medications include Cipralex, Pro-     Discuss this with them and make pression. Your treatment may be
zac and Cipramil.                      them aware of the symptoms asso- adjusted to cater for a more resis-
                                       ciated with depression.                           tant type of depression and some-
SNRI                                                                                     times more than one medication is
Serotonergic and Noradrenergic         Your performance at work will prescribed.
Re-uptake Inhibitors are medica-       decrease because of depression.
tions that increase the concentra-     Not all employers understand this A psychologist is a mental health
tion of serotonin and noradrenaline    and you may have to educate your professional who received special
in the synapse. Examples include       colleagues at work.               Tell them training at University for psycho-
Cymbalta and Efexor.                   about the symptoms of depression therapy (talk therapy). It is benefi-
                                       and the impact that it has on your cial to see a psychologist at any
DRI                                    life. Tell them that you will im- stage of your illness. Mild and
Dopamine Re-uptake Inhibitors          prove and that you will be back to moderate forms of depression are
increase the amount of dopamine        your old self again. It sometimes treated with psychotherapy. Se-
in the synapse. These medications      takes a few weeks or months, but vere depression is usually treated
also increase noradrenaline in the     recovery is the rule.


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    PANORAMA PSYCHIATRY & MEMORY CLINIC



with a combination of medication        difficult to talk about their        is an emergency then go to
and psychotherapy.                      feelings. Sometimes you have         your nearest hospital emer-
                                        to force yourself to verbally        gency unit. Or phone the SA-
There are many individuals who          express the thoughts that you        DAG (South African Depres-
receive training in counselling and     are having. Literally just start     sion and Anxiety Group) at
these persons can also help to          by saying what you are think-        011 783 1474 right now.
manage milder forms of depres-          ing. Do not be put off by
sion. Most church ministers are         thoughts like “what I am TIPS FOR FAMILY AND
trained in counselling and they         thinking is not worth it”. Start SIGNIFICANT OTHERS
often have many years of experi-        communicating your thoughts 1. Provide unconditional support
ence in working with depression.        now and with time you will           and love.
                                        see that it is beneficial and        Give your depressed family
Hospitalisation is usually indicated    easy to express your thinking.       member unconditional support
for moderate to severe depression.                                           and love. Tell them that you
It is a useful intervention to re-      You can also write your              are there for them and that no
move a depressed person from a          thoughts down in a diary or          matter what happens you will
stressful environment. It is also       other place. Writing and read-       not change your support.
possible to provide more intensive      ing what you have written
therapy during hospitalisation.         will help to lessen the pain 2. Don’t take is personally.
                                        associated with depression.          People with depression may
SUICIDAL THINKING                                                            appear to be less interested in a
Thoughts that your life is not 2. Do the basics right.                       relationship and it may be dif-
worth it and that you may want to       Make sure that you sleep well        ficult for you to accept this.
end it all are often part of depres-    and eat well. Learn about the        Know that it is a temporary
sion. Tell your doctor or psy-          principles of sleep hygiene so       thing and that the person will
chologist about these thoughts.         that you can sleep without           get better.
Remember that depression can            medications. But, if it doesn’t
convince you that the only way out      work then contact your doctor. 3. Look after your own needs.
is to take your own life. These         Also, try to schedule some           Caring for somebody with
thoughts are part of depression and     form of exercise into your           more severe forms of depres-
are not an objective assessment of      daily routine. Stick to the          sion can be very tiring. Make
reality. These thoughts are caused      routine that you may have had        sure that you have time for
by the biochemical and structural       when you were feeling better.        yourself so that you can re-
changes in your brain. Call your        It is important to force your-       cover and build your strength.
doctor at any time of the day or        self to live as if you are get-
night if you experience suicidal        ting better.                     4. Obtain help.
thoughts. You may also call the                                              Always make sure that you are
South African Depression and 3. Walk with it.                                not on your own when looking
Anxiety Group on 011 783 1474.         Sometimes you just have to            after somebody with more se-
                                       tell yourself that you are suf-       vere forms of depression.
TIPS FOR COPING                        fering from depression and            Make sure that you have help
Initially it may feel as if nothing is that there is nothing you can         and that other family members
working for you and you may feel       do right now. Just walk with          or friends understand what is
that you are rapidly loosing control   the depression and try to get         going on.
of your brain and life. Below are      on with things. You will even-
strategies that may help you to        tually get better even though FAMOUS PEOPLE WITH
cope. Read this carefully and see if   right now it may be difficult to DEPRESSION?
you can apply them right now:          imagine that it will ever be
                                       better. Just try to carry on with A number of very famous people
 1. Talk about your feelings.          your day to day routine even have struggled with depression.
      It is important to talk about    though you are carrying these These include: Billy Joel, Jim Car-
      your thoughts and feelings.      heavy feelings inside.            rey, Sheryl Crow, Brooke Shields,
      Numerous research studies                                          Terry Bradshaw, Princess Diana,
      have shown that we are able 4. Get help.                           Harrison Ford, Abraham Lincoln,
      to handle and decrease nega-     If these steps are not helpful Boris Yeltsin, Buzz Aldrin, Kurt
      tive thinking just by talking    and things are getting worse Cobain, Vincent van Gogh and
      about it. Many patients find it  then contact your doctor. If it Winston Churchill.


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