Clinical depression

• What is clinical depression?
• Statistics on clinical depression
• Risk factors for clinical depression
• Progression of clinical depression
• Symptoms of clinical depression
• Clinical examination of clinical depression
• How is clinical depression diagnosed?
• Prognosis of clinical depression
• Treatment of clinical depression
• References

What is clinical depression?

Feelings of depression may be described as feeling sad, blue, unhappy, miserable, or down in the dumps. Most of us feel depressed at some stage, but this is not clinical depression. True clinical depression is a mood disorder in which feelings of sadness, loss, anger, or frustration interfere and impede upon one’s everyday life for an extended period of time.

Statistics on clinical depression

Feeling low or sad is something that everyone experiences. Depressive symptoms are common, affecting 10-40% of people who see their GP. Feeling temporarily down is different to clinical depression, however, and only half of these patients actually meet the specific criteria used to diagnose a patient with a major depressive disorder. Still, depression remains the most common psychological disorder that a GP sees, and the rates of depression appear to be increasing even further. It is thought that depression will become the second most important disease in terms of disability and premature death, second only to cardiovascular disease.

Women

Female gender is considered a risk factor for depression. Studies suggest that 20-25% of women will be affected by major depression at some time in their life. The reason for this is not completely understood but several factors may contribute, including the high incidence of post-natal depression,  social factors (e.g. history of childhood abuse, low self-esteem), and gender differences in the metabolism of chemical signalling molecules in the brain.

Men

True depression, characterised by low mood and reduced pleasure, is becoming relatively common in men, affecting 7-12% of men during their lifetime. It is estimated that one in six Australian men suffer depression at any given time. Teenagers and elderly men have higher rates. Depression in men is associated with destructive behaviour, alcohol and drug abuse, and numerous medical disorders such as cardiovascular disease and diabetes.
The true rates of male depression may be underestimated because many males are reluctant to seek medical advice. Depression has commonly been thought of as a disease of women, although the ratio is increasing in favour of men. The increased rates of depression in men may be attributed to changing social roles. Fewer men are becoming the sole financial provider in a family, leading to a loss of social status, and to isolation. In addition, increased rates may reflect changes in diagnosis and admission criteria, or greater health seeking behaviours by men.
High rates of depression are reflected by the tripling of suicide rates for males aged 15-24 over the last three decades, making suicide the second most common cause of death in this age group. This is an alarming statistic. Furthermore, elderly men have the highest suicide rates in the country. Depression in these patients may stem from loss of spouse, isolation, financial difficulties and physical illness.

Children and adolescents

Depression in children is actually far more common than many people realise. It is estimated that one in 10 children and adolescents are suffering depressive symptoms at any one time. This equates to over 95,000 Australian children and adolescents who are affected by depression. Studies have shown that the most common time to be affected by depression is in mid to late adolescence, though it can occur at any time.
Similarly to depression in adults, depression amongst adolescents is greater in females than in males. Some studies show that up to 25% of female teenagers report depressive symptoms. In prepubertal children, the incidence of depression is thought to be about 2.5%. The actual rate might be even higher – it is hard to diagnose children, since they do not display the same symptoms. Many children find it difficult to speak about their feelings very clearly, and may often present with behavioural changes that can be difficult to identify as depression.

Risk factors for clinical depression

• Genetic cause of depression: The risk of developing depression is increased three-fold when an immediate relative is affected by depression. If you have had depression in the past, you are also more likely to develop it again.
• Physical causes of depression: Virtually all chronic diseases (including diabetes and obesity) and chronic pain syndromes are associated with depression. This is partly due to low moods over having a disease, and partly due to the disease disrupting the normal balance of chemistry within the body. Depression associated with chronic diseases can be problematic, as it can remove your desire and motivation to pursue treatment and take medications as prescribed.
• Hormonal causes of depression: There is a greater incidence of depression in patients with hormonal disorders (e.g. Cushing’s syndrome).
• Poor sleep as a cause of depression: Patients with poor sleep quality are more likely to develop depression.
• Psychological causes of depression: Physical or sexual abuse in childhood predispose adults to depressive illness. Certain personality traits are also risks for depressive illness. If you have any other psychological problems such as anxiety, you are also at higher risk.
• Social causes of depression: Traumatic life events are closely linked with the development of depression. Separation, divorce, bereavement and redundancy are all associated with depressive illness. If you are from a lower social class or are unemployed, you may also be more likely to develop depression.
• Drugs that cause depression: Chronic alcohol consumption and other substance abuse has been linked with depression.

Children and adolescents

• Genetic: 20-50% of children with depression have a family history of the illness, and children of depressed parents are up to three times more likely to experience depression.
• Environmental: The home and school environment in which a child is brought up can influence the chance of experiencing depression. Factors such as high levels of conflict within the home, or an early death of a family member, increase the chances of a child experiencing depression. Sexual, physical and emotional abuse can also contribute.
• Negative life events: Events such as parental divorce, poor social relationships, death of a family member or friend, and other negative experiences are reported more commonly in adolescents suffering from depression.
• Personality characteristics: Some personality types are particularly prone to adolescent depression. Those with attributes such as high levels of anxiety, low self-esteem, high self-criticism and poor school performance are more likely to have depression.

Progression of clinical depression

Unlike feeling gloomy or having a bad day, as happens to all of us from time to time, the symptoms of a severe clinical depression usually occur in episodes that last for ten months. During this time, the symptoms of depression will be more pronounced, with the sufferer becoming socially withdrawn and subjectively depressed. At these times, patients are more vulnerable to acts of self-harm and suicide attempts. Sometimes patients suffering depression will need to be observed more closely to prevent these events from occurring.

Children and adolescents

There are a few long-term consequences associated with major depression, especially in children. There is some evidence, though not conclusive, that depression during early and late adolescence is associated with later obesity, especially in females, and that the more episodes of depression there are, the higher the level of obesity. Depressed adolescents are more likely to be involved in unsafe sexual practices and other risky behaviours. It can lead to some negative outcomes such as:

• School failure;
• Substance abuse;
• Early pregnancy;
• Social isolation;
• Poor physical health.

This does not mean that all depressed children will experience these things; it just reinforces that depressed children need to be treated and monitored very closely to prevent these kinds of problem from occurring.

Symptoms of clinical depression

The two most classical feature of depression are a low mood, and reduced pleasure form activities that were previously considered pleasurable. In true clinical depression, these feelings have lasted a while and are now starting to impact your life in negative ways. If depression is severe you may develop a very grey view of the world, and overwhelming feelings of worthlessness, hopelessness and guilt. In advanced stages you may feel like hurting yourself, or you may have thoughts of suicide.
However, depression does not always present so obviously. You may notice you feel tired, run-down or have other vague symptoms such as abdominal pain or headaches. It may not be until your doctor asks several detailed and specific questions about your specific symptoms, mood and lifestyle that you realise you are depressed.

Children and adolescents

Symptoms in children and adolescents are the same as in adults, but because some children react to emotional states differently than adults, they may seem different. Some symptoms that appear to be more common for children and adolescents include:

• Mood changes: Increased irritability, anger, or hostility;
• Boredom;
• Reckless behaviour;
• Outbursts of shouting, complaining, unexplained irritability, or crying;
• Poor school performance;
• Fear of death;
• Alcohol or substance abuse;
• Frequent nonspecific physical complaints such as headaches, muscle aches, stomach aches, or fatigue.

Clinical examination of clinical depression

Your doctor will perform basic tests to determine your mental state and mood. It is also likely he or she will perform some examinations to exclude other diseases that can preset with depression. In particular, your doctor will do a general inspection, and examine the thyroid, chest, abdomen, and perhaps the neurological system, looking for any related diseases.

How is clinical depression diagnosed?

Depression may be caused by a variety of physical problems within the body (called “organic”) Such problems include electrolyte disturbances, thyroid disease, anaemia, chronic infection and malignancy (cancer). You will need to have a series of baseline blood tests to exclude anything that may be contributing to your depression.

Prognosis of clinical depression

Most patients with depression will recover from their condition after 6-12 months, depending on the severity. About a quarter of patients attending hospital with depression symptoms will experience depression again within a year of treatment, and three quarters will experience it again within 10 years of treatment.
If you suffer from recurrent episodes of depression, you may be recommended treatments to help prevent depression. This may involve cognitive behavioural therapy that concentrates on relapse prevention, other forms of psychotherapy, or antidepressant medication. Full-dose antidepressants are probably the most effective way to prevent recurrent symptoms of depression.

Children and adolescents

Roughly 40% of depressed adolescents will continue to have depressive symptoms after 4 years, and up to 70% will have a relapse by adulthood. For this reason, it is important that all children with depression are closely monitored so that they remain adequately treated.

Treatment of clinical depression

The treatment of depression symptoms involves physical, psychiatric and social interventions. An initial step in management is educating the patient about the condition and its implications. Often just knowing that self-loathing, guilt and suicidal thoughts are caused by the illness can help you take the first step in pursuing treatment for depression.
Many men do not seek medical advice for depression because they think it is a sign of weakness. However, it is important for all depressed patients to see a doctor. Friends and family may need to encourage and persuade men to see a doctor to avoid the depression getting out of hand and, in the worst scenario, leading to suicide. An overview of treatment principles for depression is provided below.

Physical treatment for depression

1. Cease use of depressant drugs (including alcohol and steroids).
2. Keep co-existing medical conditions under control with their recommended treatments.
3. Regular exercise can help mild to moderate depression.
4. If excess weight is contributing to your low mood, it may be helpful to lose some weight.
5. Antidepressants (sometimes referred to as ‘happy pills’) can help to elevate your mood in the early stages. Your doctor will decide the best agent based on side-effects, any other illnesses and interactions.
6. Electroconvulsive therapy is the depression treatment of choice in severe life-threatening depressive illness, particularly when psychotic symptoms are present. Here, the patient is induced to have an epileptic fit up to three times a week for 3-6 weeks.

Psychological treatment of depression

1. Education and regular follow-up by a psychiatric professional. Cognitive behavioural therapy (this is the most effective psychotherapy for clinical depression).
2. Other indicated psychotherapies, such as couple, family and interpersonal therapies.

Social treatment for depression

Depending on your circumstances, there are a variety of ways that your doctor and agencies can try to help to reduce the stressors in your life. This may include:

1. Financial assistance, such as eligible benefits and debt counselling.
2. Employment assistance, such as helping you acquire a job or change career.
3. Housing assistance, such as ensuring an adequate and secure tenancy and safe, social neighbours.
4. Assistance with young children, such as child-care support.

Overall, the most effective treatment for depression is a mixture of cognitive behaviour therapy and an antidepressant medication.

General advice

If you are depressed, it may be important that you hold off making large and important life decisions until you have an adequate response to treatment. This will help you avoid making decisions that you may regret later. Your doctor may be able to help you gauge when you have reached this stage. If you are actively suicidal, severely depressed or have psychotic symptoms, you require hospital admission to prevent harming yourself. Admission to hospital is usually necessary for 1 in 1,000 depressed patients with clinical depression and primary care. A short stay in hospital gives you a break from caring for yourself and allows support, listening, observation, prevention of suicide, and close monitoring of depression treatments.
In most cases, depression should be treated even if it seems an understandable reaction to serious illness or difficult circumstances. If you are elderly, severely or even terminally ill, you are probably more likely to become depressed. Remember that depression can have significant consequences and impede your quality of life, therefore treatment would be beneficial.

Children and adolescents

Treatment in children and adolescents is much the same as for adults. Education is especially important, as patients often enter treatment thinking of the stigma associated with depression. Discussing the very common nature of depression in childhood and adolescence can be useful, as can carefully explaining that it is in no way a character flaw but rather a medical condition. Encouraging patients to engage more in school and increase activities with their friends can also help treatment, and physical activity can decrease depressive symptoms.
Treatment with medication is occasionally controversial, but is highly effective in reducing depressive symptoms. While there has been a lot of negative press about some children having more suicidal thoughts when placed on SSRIs, this is a far from proven conclusion and more research needs to be done. So far, though, it seems that the benefits of treatment outweigh the risks. For safety, however, patients who are placed on these medications should have the potential risk assessed and the side effects explained in detail, and should be closely monitored.
Drug treatment with a single SSRI along with some form of psychotherapy is the recommended first-line treatment for an adolescent or child with depression. If there is no response to the medication, then an increased dose can be tried. If this is also unsuccessful, a different agent should be used. Up to 50% of patients who are initially unresponsive will find an effect from a different medication.

Useful resource

The MindSpot Clinic is a free telephone and online service for Australian adults troubled by symptoms of anxiety or depression. The service is run by a team of health professionals and provides free Online Screening Assessments, free Treatment Courses and can assist in finding local services that can help. To speak to one of the team call 1800 61 44 34 between 8am -8pm AEST Monday to Friday and 8am – 6pm AEST on Saturday or visit MindSpot Clinic.

More information

For more information on how psychotherapy can be used in the treatment of depression, see Psychotherapy for Depression

References

1. Aronson S. ‘Depression,’ eMedicine, 2005.
2. Burns J, Andrews G, Szabo M. Preventing Depression. Depression in young people: what causes it and can we prevent it? MJA 2002; 177(7): S93-6.
3. ‘Depression in Children and Adolescents’ [online]. National Institute of Mental Health, 2006. Available from: [URL Link] (last accessed 07/08/07)
4. Ellen S, Selzer R, Norman T, Blashki G. Depression and anxiety – Pharmacological treatment in general practice, Australian Family Physician 2007; 36(4); 193-288.
5. Hickie I. Preventing depression: a challenge for the Australian community, MJA 2002; 177(7): S85-6.
6. Johnson C. Managing mental health issues in general practice, Australian Family Physician 2007; 36(3): 202-5.
7. Kumar P, Clark M. Clinical Medicine. Fourth Ed. WB Saunders, 2002.
8. Patten CA. Choi WS. Vickers KS. Pierce JP. Persistence of depressive symptoms in adolescents. Neuropsychopharmacology. 2001; 25(5 Suppl): S89-91.
9. RACGP Online- Depression in Men, Australian Family Physician, 2001.
10. Richardson LP, Davis R, Poulton R et al. A longitudinal evaluation of adolescent depression and adult obesity. Archives of Pediatrics and Adolescent Medicine. 2003; 157(8): 739-45.
11. Richardson LP. Katzenellenbogen R. Childhood and adolescent depression: the role of primary care providers in diagnosis and treatment. Current Problems in Pediatric & Adolescent Health Care. 2005; 35(1): 6-24.
12. Sadock BJ, Sadock VA. Kaplan and Sadock’s Pocket Handbook of Clinical Psychiatry 3rd Edition. Lippincott Williams and Wilkins, Philadelphia USA.
13. Saluja G, Iachan R, Scheidt P et al. Prevalence of risk factors for depressive symptoms among young adolescents. Arch Pediatr Adolesc Med. 2004; 158: 760-5.
14. Shajahan P, Cavanagh J. Admission for depression among men in Scotland, 1980-95: retrospective study, British Medical Journal, 316: 1496-7.
15. Voelker R. Researchers probe depression in children. JAMA. 2003; 289(23): 3078-9.