Preview of Understanding Depression

Family Doctor Books

Published in association with the British Medical Association

Family Doctor Books

Preview of Understanding Depression

Depression is an illness of mind and body. Most people have both physical and psychological symptoms, but their exact nature will vary from one person to another. Different symptoms will be more or less prominent in each person’s illness. Some people report no symptoms at all but begin behaving in an unusual way – for example, one previously law-abiding woman who came to my clinic had started shop-lifting when she became depressed.

SYMPTOMS OF DEPRESSION

Psychological

Low mood
Loss of interest in things you used to enjoy
Anxiety
Emotional numbness
Depressive thinking
Concentration and memory problems
Delusions
Hallucinations
Suicidal impulses

Physical

Sleep problems – difficulty getting to sleep, waking up early or sleeping too much
Mental and physical slowing
Increase or decrease in appetite
Increase or decrease in weight
Loss of interest in sex
Tiredness
Constipation
Period irregularities

Psychological symptoms

Low mood: Despite the use of the label depression, not everyone with this illness feels low. Some are anxious, some say they are emotionally numb and some have no mood changes but come to their doctor with unexplained physical symptoms or with a change in behaviour.

Low mood in depression is much more intense than the way you feel when you are disappointed or just fed up. It is a persistent feeling of sadness, emptiness, loss and dread. Some say it is like living with a cloud over you and it takes over every part of your life. In moderate or severe depression, low mood is often worse in the morning and improves slightly during the day – though it never goes. This is called diurnal variation.
Low mood makes it impossible to enjoy anything and you may even lose interest in your hobbies. Nothing brings you pleasure. Doctors call this symptom anhedonia.
In some milder depressions low mood may be worse in the evenings than in the mornings and there may be the odd good day. However, these are outnumbered by the bad ones. If depression is mild you may be able to enjoy other people’s company – though without stimulation you would soon become disenchanted again.
With the low mood comes a tendency to cry more often, with the slightest upset or even with no upset at all.

Anxiety: When we feel threatened, a hormone called adrenaline is released and blood is directed to our muscles and brain so that we can think quickly and flee if we need to. We feel on edge, jumpy and tense but, if nothing happens, the feeling passes off in a few minutes. In someone who is depressed, these anxious feelings can last for months. Some people wake in the morning in a state of high anxiety because they dread the day ahead. Anxiety can outweigh low mood and be the most prominent symptom in depression. If you are in a state of anxiety you may find that you get irritable and snap a lot which is obviously difficult for other people to live with as well as for you.

Emotional numbness: Some people who are severely depressed say they feel like they have completely lost their emotions and this is one of the most distressing symptoms of depression. You feel numb. You can’t cry and feel like there are no tears left. You may not feel that you are part of the world because you do not think you have feelings. You may feel distant and unfeeling about even people very close to you like your partner, family or children.

Depressive thinking: Your thinking changes when you are suffering from depression. You see the world differently and everything appears in a negative light. This distorted view simply reinforces the depression.

You may blame yourself for unfortunate events more than you should while not allowing yourself to take credit for things you have done well. The good things that you have done throughout your life are forgotten and the bad are vividly remembered and blown up out of all proportion.

You may find yourself concentrating on the negative detail and ignoring the bigger picture. To take an extreme example, someone who had passed an exam with 99 per cent might ignore the good result and concentrate on the one per cent that they got wrong.

You may also start jumping to negative conclusions and jumping to general conclusions from single events. For instance, a model I once treated thought that she was ugly and everyone hated her because a man who passed her in the street gave her a funny look.

These sorts of negative thinking patterns undermine you. They lead to worry, a lack of confidence and feelings of worthlessness, and your world becomes full of gloomy thoughts, self-doubt and anxieties. As a result, you feel more depressed or anxious and so a vicious circle is set up.

Concentration and memory problems: If you are consumed by worries and depressive thoughts it can be difficult to think about anything else. You may find it difficult to concentrate and this leads to problems. You have to concentrate on something to remember it, so it is not surprising that poor concentration and memory problems go together. Problems with concentration also lead to indecision and inattention; you may feel muddled and confused. These can be so severe as to be mistaken for dementia.

Delusions and hallucinations: If you should become severely depressed, your thinking can become so distorted that you lose touch with reality. Your mind can start playing tricks on you and you may even fear that you are going mad. You are not; you are severely depressed and will get better with treatment. Delusions can occur in severe depression; thankfully they are rare because they are so distressing.

A delusion is a false belief which is held unshakeably by the person who has it. In depression delusions reflect and reinforce the depressed mood as happened with James whom I treated some time ago. He believed that he should give himself up to the police because he had left a shop without paying for an apple by mistake five years previously. He thought that the police were looking for him and that there was no way out. He believed that he had brought shame on his family and was worthless. It was impossible to make him believe that he was not public enemy number one, that anyone could make a mistake and that no one would be bothered about it.

Other people believe they are the most wicked person in the world or that people want to get rid of them because they are so bad. Some people believe that they have no money at all; others that they are decaying or even that they are dead. There are as many different types of delusion as there are ideas in the human mind but all of them reflect the depressed mood and depressive thinking.

Whereas delusions are false thoughts, hallucinations involve perceiving things that are not real – usually sounds. For example, some severely depressed people hear voices when there is no one there. The voices sound like people in the room talking to them and are frighteningly real. The voices may criticise them or tell them they are bad. The voices reinforce the depression. Some people see or smell things that are not there but this is rarer.

Suicidal impulses: When you are in the depths of depression the past looks bad and full of mistakes, the present is awful and you dread the future. Some come to the conclusion that life is not worth living, that every- one would be better off without them and that they should take their own life.

Many depressed people think about suicide – even if it is just a passing thought. Many do not actually contemplate committing suicide but go to bed at night hoping that they will not wake up, and so get away from the terrible torture of living.

Most people decide that they can’t do it, perhaps because it would be too drastic, or the effect it would have on their family or because of religious beliefs. Some people come to the conclusion that they have not done it because they are cowards and this makes them feel even more ashamed and depressed.

If you think about suicide you are at risk of doing it. Get help urgently: see a GP, go to an accident and emergency department or call the Samaritans. Depression can be treated.

DEPRESSIVE THINKING

There are three elements to depressive thinking:

Negative thoughts, for example, ‘I am a failure at work’
High, unreasonable expectations, for example, ‘I cannot be happy unless everyone likes me and thinks I am good at my job’
Mistakes in thinking, for example:
(a) jumping to negative conclusions
(b) focusing on negative details of a situation and ignoring the good bits
(c) coming to general conclusion on the basis of a single incident
(d) coming to the conclusion that things that are nothing to do with you are your fault

CASE HISTORY

Carrie is a secretary; her boss is late for the train and on his way out says, ‘Could you type this report up for me, I have made a few corrections’. Carrie is depressed, and because of this she thinks she is a failure. She believes that she has to correct the report because she is bad at her job. She becomes more depressed because she has the unreasonable expectation that she must be perfect in her job if she is to enjoy her life.

In reality, she is good at her job but she doesn’t think so. She concentrates on little things that go wrong rather than the big things that go right. She forgets the fact that she was given a pay rise because her company value her so much. She also ignores the fact that her boss is known to be indecisive and always changes reports that he has written. She concentrates on the negative details and jumps to a general conclusion based on a single incident – this makes her depressed.

While she is typing the report another thought comes to her: ‘Could the boss be late because he had to correct my sloppy work? If the deal falls through it will be all my fault!’ She blames herself for things that are not her fault which fuels her depression.

Physical symptoms

Depression can cause a number of physical symptoms. Those people affected often come to the conclusion that they have a physical illness because they feel so tired and off-colour or are in pain.

Sleep problems: Sleep problems are common in depression and are sometimes partially to blame for the tiredness that may be experienced. If you are suffering from a moderate or severe depression you may wake up in the morning hours earlier than usual and then find it impossible to get back to sleep. All depressed people can find it difficult to get to sleep because they worry and may suffer from broken nights – wak- ing up a number of times before the morning.

Mental and physical slowing: If you are depressed you may feel like a machine which is seizing up. You feel tired all the time, it is hard to perform everyday chores, everything is an effort and it seems as if everything is slowed down. Your speech may be slow and monotonous and you may even move slowly. Doctors call this psychomotor retardation.
Sometimes body functions slow down or seize up as well. You may find that you have a dry mouth or that you become constipated; some women stop having periods or they may become irregular.

Loss of appetite: When you are depressed you can lose quite a lot of weight. Food seems unappetising and bland and you don’t even feel hungry. Some people with severe depression completely stop eating and drinking, but this is rare.

Reverse physical symptoms: Instead of the normal physical symptoms of depression like poor sleep, loss of appetite and loss of weight, some people have what are known as reverse physical symptoms. They sleep more, have a bigger appetite and gain weight. If you feel low in mood and have these symptoms you should see your doctor.

Other physical symptoms: Depression can produce just about any physical symptom. Pain and a feeling of pressure are common, most often affecting the head, face, back, chest and gut. People frequently come to hospital accident and emergency departments complaining of chest pain and worried that something is wrong with their hearts, when in fact they are suffering from depression. The pain is real but is caused by depression; there is nothing wrong with their hearts.

Sex: Many people go off sex when they are depressed. There are many reasons for this. Some people do not feel able to fulfil a physically loving relationship when they are emotionally numb. Other people feel so negative about themselves that they cannot relax. These psychological problems can lead to physical problems: men may find it difficult to get an erection and women may find that they are dry and that intercourse is painful. Many people who are depressed cannot say why but just do not feel interested in sex.

‘Smiling’ depression: Not everyone with depression feels low – some people say they do not feel depressed but go to their GP with bodily symptoms such as pain, headache or tiredness that point to depression. Physical examination and investigation do not reveal a physical cause for their illness and the only treatment that works is antidepressant medica-tion. It may be that their subconscious mind is playing tricks on them and does not allow their conscious mind to admit that they feel depressed.

What causes the symptoms?

The symptoms of depression may be caused by low levels of certain chemicals in the brain. To understand why this might be, we need to look at how the brain works. It is made up of billions of nerve cells. It can take hundreds of them to carry out any action, even to think about doing something. In order for nerve cells to work together they have to communicate with each other and they do this by releasing chemicals called neurotransmitters.

Between the end of one nerve cell and the next there is a small space called the synapse. The first nerve cell communicates with the next by releasing neurotransmitters into the synapse. These neurotransmitters attach to the next nerve cells and so pass on the message.

Studies have shown that three important neurotransmitters, dopamine, serotonin and noradrenaline, are in short supply in depression. The levels are low in synapses, and this leads to faulty brain communication and message passing which may be the cause of depressive symptoms.

Nobody knows what causes these low levels of chemicals. Scientists do not know whether they cause the depressed mood or are caused by the depressed mood. It may be that low levels of neurotransmitters are caused by stress and then they lead to depression. Antidepressant drugs work by increasing the levels of these chemicals.

How nerve cells transmit messages.

The role of hormones

Hormones may be important in causing the symptoms of depression. We have seen that adrenaline causes anxiety and the role of female hormones in depression is discussed later. Another hormone that may be important in depression is cortisol.

Cortisol is important in our body’s reaction to stress. Cortisol has wide-ranging actions on all parts of our body metabolism so that we are ready for action in an emergency. It changes our immune reaction, our kidney function and the levels of fats and sugars in our blood. Its release, which is controlled by the pituitary gland in the brain, does not follow the normal pattern in people who are depressed. In healthy people, cortisol is usually released in large quantities in the morning and diminishing amounts throughout the day, whereas in some depressed people its release is the same all day long. Nobody knows whether this leads to depression or is the result of it but cortisol does affect the levels of neurotransmitters in the brain.

Changing levels of cortisol in the body have led to a test for depression, but it is not that sensitive and only works in about three out of ten people. It works best in those who have serious depressions with physical symptoms.

KEY POINTS

Depression has physical as well as mental symptoms
Symptoms vary from person to person
Anyone who thinks about suicide is at risk of doing it and should seek help urgently

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