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By Suzann Ogland-Hand, PhD
Whether we typically view the glass of water as half empty or half full – whether
we are normally pessimistic or optimistic – we all have times when
we feel down. The causes can range from tragic, lifechanging events like
the loss of a spouse or the loss of job to hassles or temporary annoyances,
like rain on our vacation or a disagreement with a friend. We may feel
overwhelmed, hopeless, or irritable. At times, we may think nothing is
going right.
These are normal feelings and thoughts we all experience. Often, these
feelings and thoughts are short-lived. They may impact our behavior for
a few hours or a couple of days. We recognize these thoughts and feelings
are only temporary.
However, if the symptoms of depression last for two weeks or longer
and interfere with our day-to-day functioning, we may have crossed into
a clinical depression. This may be a “major depression” that
requires treatment.
What Is Depression?
Depression is one of the most common of all behavioral health problems,
affecting two out of ten Americans.
How can you tell if someone has a major depression? There are signs
we can look for in ourselves and people we care about. (See box on page
16) Classic symptoms of depression fall into three categories: affective,
cognitive, and behavioral.
Affective symptoms mean our current emotional state – what we
call feelings. Depressed people may feel sad. Their low spirits may persist
even if they hear good news or are involved in activities they used to
enjoy. Some depressed people are tearful. No matter how hard they (or
their loved ones) try to change their mood, they can’t overcome
their blue feelings.
Cognitive symptoms mean how we think. Depressed people often have thoughts
of hopelessness and worthlessness. They may find it hard to concentrate
and make decisions. They may have recurring thoughts of death or suicide.
Behavioral symptoms mean a physical response like fatigue or insomnia.
Some people experience changes in their appetite, sleep patterns, and
sexual desire. They may have physical complaints that have no physical
cause. Sometimes they withdraw from normal life activities and relationships,
maybe even neglecting to take care of themselves, and spending most of
the day in bed.
In some cases, people may experience disordered and disturbed thoughts
with depression. They may hear voices or sounds other people don’t
hear (called “auditory hallucinations”) or see images other
people don’t see (“visual hallucinations”). Sometimes,
people have thoughts of wishing they were dead. Some have plans of how
to end their life or have tried to hurt themselves. If you or someone
you care about is having thoughts like these, seek immediate help.
While symptoms of major depressive disorder are similar for younger
and older adults, some subtle differences may exist. Older people with
depression have more memory complaints, more self-reproach, and less
guilt than younger adults. They are less likely to complain of sadness,
but are more likely to report negative moods such as agitation, irritability,
anxiety, and anger. Further, while anhedonia (the loss of ability to
experience pleasure in activities a person used to find enjoyable) is
a symptom of depression at any age, it’s especially prevalent with
older people. Finally, healthy older adults often show changes in weight,
sleep, appetite, and energy levels, so differentiating normal aging from
depressive symptoms is challenging.
Risk Factors for Mood Disorders
What causes depression? People can become depressed from a combination
of psychosocial factors, situations in their lives, and biological issues.
Depression is associated with increased stressors and negative life
events. Many different factors can contribute to a person becoming depressed.
Some include:
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Inadequate coping strategies
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Lack of social support
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Poor communication skills
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Low self-esteem
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Feelings of inadequacy
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Losses (child, spouse, friend, independent living, economic freedom)
•
Survivor of abuse or neglect
•
Few experiences of competency
Changes in life roles (for example, with retirement) can be instrumental.
People may not experience as many reinforcements as they once did. This
may be from fewer job or social interactions, less participation in hobbies
or activities, or a reduced ability to accomplish physical tasks. They
may be a primary caregiver, that is, helping with another person’s
basic daily functioning, a role with practical and emotional demands.
Some people may be genetically predisposed to getting depression. There
is evidence that mood disorders run in families, so they may be more
vulnerable to becoming depressed, especially if they get in stressful
situations.
Some people may become depressed after physical health complications.
They may become physically disabled or lose a pain-free existence. They
may experience depression as a side effect of medication.
Depression Assessment
A thorough evaluation is necessary to diagnose depression. A health
care professional – family physician, psychologist, social worker,
or psychiatrist – makes a diagnosis of major depressive disorder.
Professionals often use these three questions to help adults older than
60 decide if they would benefit from an evaluation. They may help any
adult take that step.
1. Are you basically satisfied with your life?
2. Are you hopeful about the future?
3. Do you often feel downhearted
or blue?
If you answered any one of these questions in the “depressed direction” (1.
No, 2. No, 3. Yes), you would likely benefit from an evaluation for depression.
A thorough assessment for depression is especially important for an
older adult. Many older people have chronic medical problems like hypothyroidism,
hypertension, or arthritis. Sometimes, the side effects of medications
they need to manage their chronic illnesses may mimic symptoms of depression.
For example, if someone has hypothyroidism and isn’t on the right
level of thyroid replacement, they may feel lethargic and have low energy.
In addition, sometimes a common chronic illness like arthritis or diabetes
can trigger a depression.
Further, older adults may be reluctant to discuss or admit their psychological
symptoms. Effective treatments for depression have only existed in the
past 50-60 years. Many elders have memories of people from their parents’ and
grandparents' generation who suffered silently with
disabling symptoms of depression since no treatment was available.
Another factor complicating assessment is that often older
adults, as well as health care providers, have biases because of a person’s
age. For example, they may believe that psychiatric problems – and
depression in particular – are a normal part of aging. These beliefs
lead people to think mistakenly that depression is inevitable and can’t
be treated. In fact, depression is not a normal part of aging, and treatment
is available.
Once you are better from an episode of depression, you need to focus
on staying well. We know that depression is a chronic health problem,
meaning that once you have one episode of depression you are at risk
for a future episode. It is typically within the first 6-12 months after
a person recovers from an episode of depression. When you are doing really
well and fully functioning again, you are at the highest risk for a relapse
of depression.
That means a focus on staying well plus an understanding of the triggers
that indicate another episode may be starting are very important. Applying
specific strategies to your life to stay well is important if you’ve
ever had even one episode of depression.
Treating Depression
Depression is one of the most treatable of all mental illnesses. Between
80-90 percent of people who suffer from depression can be effectively
treated. Nearly all depressed people who receive treatment see at least
some relief from their symptoms. That means if you or someone you care
about is having symptoms of depression, help is available. Remember,
too, that people who are depressed may not have the energy to seek treatment
on their own. They may need someone who loves them to express concern
and help guide them to seek treatment.
Many people with major depressive disorder get the help they need through
outpatient treatment. Sometimes more intensive programs like partial
hospitalization or inpatient treatment are necessary. This is usually
only if the depression is prolonged and includes suicidal thoughts, disturbed
thinking, or an inability to take care of themselves.
The most commonly used treatments are psychotherapy, pharmacotherapy
(taking antidepressant medication), or a combination of the two. Self-administered
treatment using bibliotherapy has also proved useful.
Psychotherapy
Psychotherapy, also referred to as therapy or counseling, involves talking
with a trained psychologist, social worker, or other mental health care
provider to learn effective ways of handling problems. Short-term psychotherapy
with adults can be effective in treating depression. Some people prefer
psychotherapy over antidepressant medication because it avoids the drug
side effects. Six to ten sessions help most people with less severe symptoms
feel better. A person’s situation and symptom picture (i.e., how
complicated the problems are, how long a person has been suffering with
untreated depression) will determine the length of treatment. It is not
uncommon for people who have complicated situations or have been troubled
with recurring episodes of depression throughout their lives to need
twenty sessions or sometimes more.
Cognitive-behavioral therapy helps change negative styles of thinking
and behaving that may contribute to depression. If depressed people learn
new patterns of acting, thinking, and feeling, they can control depression
and make it less likely to occur in the future. In this therapy, the
goals are to:
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Help the person enjoy life
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Change negative thinking (like helplessness and hopelessness)
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Recognize cognitive (thinking) distortions (like catastrophizing and
overgeneralizing)
(See Side Bar on “Learned Optimism”)
It may include social skills training, relaxation training, behavior
diaries (monitoring mood, sleep), reading, and homework between sessions.
Pharmacotherapy: Medications
There are now more than a dozen effective antidepressants on the market.
They are most commonly prescribed by psychiatrists and primary care physicians.
Some of the newer antidepressant medications, SSRIs (selective serotonin
reuptake inhibitors), are safer and have fewer side effects than other
drugs. Typically, these medications take two to four weeks to begin working.
Certain medications work better for some people than others. It’s
important to talk to your doctor about finding a treatment that fits
your lifestyle and needs. When taking antidepressant medications, you
can experience side effects, and often those side effects will go away
as your body gets used to the medication. It may be necessary for your
doctor to try different medicines at different doses; this is fairly
common. It is typically recommended that antidepressants be continued
for six to twelve months after a person is better, to minimize the risk
of relapse.
Self-Administered Treatment: Bibliotherapy
Research also shows some people with only mild or moderate levels of
depression can get better from “bibliotherapy.” Bibliotherapy
is self-administering treatment to yourself by reading one of two books
and applying those principles to your life to make things better. The
two books that have scientific principles about depression treatment
are: Feeling Good by David Burns, and Control Your Depression by Peter
Lewinsohn et al. These books are understandable and available at your
local library or in paperback from your local bookstore.
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Feeling Good offers a cognitive approach. That is, focusing on how your
thoughts influence how you feel.
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Control Your Depression offers a behavioral approach. That is, focusing
on how your behavior and what you do influence how you feel.
What is remarkable about this treatment is that it helps many people
with mild symptoms get well and also stay well. It’s also very
low cost.
If you try this self-administered treatment and it isn’t working
alone, do consider also contacting a mental health professional. He or
she can work with you and continue to individualize treatment to address
your needs.
ECT
Another effective treatment for depression is electroconvulsive therapy
(ECT). ECT involves an electric current that is used to produce a seizure
in the depressed person. We think it results in the release of chemicals
in the brain that help communication between nerves and helps someone
feel better. ECT works quickly, and is often effective when other treatments
fail. It is especially useful in cases of severe depression, where delay
in treatment response could be life-threatening, or where all other treatments
options have not helped.
Get Help For Yourself
In addition to professional help, we can help ourselves prevent depression.
One sad day isn’t abnormal. But if you have several in a row, you
need to take care of yourself.
Stay connected to other people. Is there someone you can talk to? This
doesn’t necessarily mean making an appointment with a mental health
professional or clergyperson. It may mean doing what you know will make
you feel better. Maybe you should call your sister in Oregon or that
old school friend.
Do something you enjoy.
Experience pleasure and enjoyment each day. Take the afternoon off to
walk on the beach. Hit nine holes of golf this evening. Wander through
an art museum or the book store. Prepare a gourmet meal. We all have
activities we enjoy, and participating in these each day helps prevent
depression. Choose activities that are meaningful to you. What’s
important is to do something you enjoy. Focus on areas of pleasurable
social activities and activities where you feel a sense of competence,
meaning, and purpose. Learn how to experience positive emotions, broadening
and building on them. (See The Role of Positive Emotions:
Broaden and Build).
Summary
We all have times of sadness and loss. We can help ourselves handle
them and possibly prevent more severe depression. Listen to your own
thoughts and feelings so you know what your needs are and what changes
you must make. Talk with others who care about you. Take care of yourself
by continuing to be engaged in activities you enjoy. And if you – or
someone you care about – shows signs of experiencing depression,
get help. It’s the most important step you can take.
Suggestions for Further Reading
Burns, D.D. The Feeling Good Handbook Burns, D.D. Feeling Good: The
New Mood Therapy Jakubowski, P. and Lange, A.J. The Assertive Option:
Your Rights and Responsibilities Lewinsohn, Munoz, Youngren, & Zeiss.
Control Your Depression Seligman, Martin. Learned Optimism
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