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8. Who gets depressive illness?

8.1 Depression in children

Depressive symptoms or features (as opposed to depressive illness) are common in emotionally disturbed children. Serious depressive illness in children is very uncommon and may occur in about 1 in 1000 children aged 10–11. Less severe depression occurs in about 2 children in 100. Much more commonly in children, depression is expressed as a behavioral disorder, or shows itself with bodily complaints, e.g. worry about health, abdominal pain, headache and fatigue.

Deliberate self-harm and suicide are exceedingly rare before adolescence. Teenagers’ worries about growing up often include weight, appearance, relationships, sexual orientation, and what other people will think about them. All of these difficulties are helped by talking, although some – such as being uncertain about one’s sexual orientation – may still not be easy to discuss nowadays.

Children and adolescents can be treated with antidepressants. Usually the newer antidepressant drugs (SSRIs) seem to be more effective than the old-fashioned drugs. A central and key part of treating a child or adolescent who is depressed is working with the family to help them make necessary changes. Involving school or college is not only advisable but is likely to be extremely helpful in the treatment of a depressed young person. Depression in a child or adolescent may be a sign that something very serious is wrong in the family, the environment or at school. Looking at, and trying to deal, with difficult social, family or school situations may do as much as, if not more than, medication can usually do.

8.2 Adolescence and depression

Before puberty the rate of depression in boys and girls are equal. After puberty twice as many girls as boys become depressed. About 5 adolescents in 100 become depressed. Depressive illness in adolescents can be difficult to spot. Anger, irritability, withdrawing from friends and alienation from parents, academic underachieving, low self-esteem and sadness may all indicate depression – or be a reflection of the challenges and turmoil of normal adolescence. The changes brought about by depressive illness in adults are also seen in adolescents, but sleep disturbance is less common (adolescents are famously good at sleeping!). Delusions (abnormal beliefs) and hallucinations (abnormal perceptions) are less common than in adults.

Depression in adolescents, as in adults, may be linked to excess alcohol. Parents are often unaware of how much their child drinks – the average alcohol intake in a 15-year-old is 7 units a week. Some will drink nothing, others the average amount, and others far more. Adolescents may start to drink to try and make themselves feel better. The same is true of street drugs. Once alcohol or substances are used regularly, secondary problems occur. Finding the money to fund the habit becomes very difficult, and the problems rapidly compound. There is more information about alcohol and substance abuse later in this course.

The disturbing rise in suicide rates in 15 to 19-year-olds may well be linked to the increase in alcohol consumption and the use of street drugs in this age group. It is never helpful to think that your child would ‘never do such a thing’. There is huge peer pressure on adolescents to drink or take street drugs – they are all very vulnerable.

My daughter is 14 and I think she’s really depressed. I know-how she feels because I went through the same thing in my late teens. I’ve asked my GP about putting her on Prozac or something similar, but she seems reluctant. Shouldn’t she prescribe it for her?

 Teenagers and younger children can certainly become seriously depressed. Adolescents need careful treatment because they are going through all the stresses of adolescence, because they are growing rapidly and facing all sorts of new challenges in their lives, and not least because it’s not easy to know what they’re thinking. Also, children might go to the doctor with physical symptoms, so that depression is visually very hard to recognise.

Antidepressants of some sort may well be very helpful for your daughter.

However, many family doctors would wish to ask the advice of a psychiatrist with special skills in this situation rather than engage in treatment of someone so young themselves. There are specialised counselling services for teenagers but, if she seems seriously depressed at her age, she definitely needs medical attention too. Ask the doctor to refer her to a child psychiatrist.

My nephew was treated for depression aged 18. He’s OK now, and at University, but takes his final exams next year. We’re worried how he’ll cope with the stress.

First of all, make sure he knows that you are helpfully concerned, that he can talk to you if he runs into a problem, and that you will keep in touch with him yourselves just as general friendly support. Looking after him generally is important, and we will suggest a number of self-help tactics later. Secondly, be sure that he is aware of the sources of help if he does start to feel under stress or overwhelmed. These start with his tutors, and would include the University Health Service, local counseling services (most Universities have their own counselors) and phone help lines.

My teenage nephew used to be quiet and generally kept a low profile. Over the past few months he has taken to riding his motorbike very fast and has had a whole string of girlfriends.

 The distinction between reckless behavior and what normal young men do for fun may be a very fine line. There may be nothing wrong. Recklessness, however, can be part of a breakdown of normal behavior in the setting of drinking too much, or taking street drugs – both of which numb judgment. The risk-taking behavior can also include unprotected sexual activity or having sex with multiple partners. Any marked change in behavior in a young man should alert those around him to the possibility of substance misuse. Occasionally some more risky behavior emerges from self-destructive thoughts arising in a depressive illness.

8.3 Women-Postnatal problems

My wife became very withdrawn and low when she had our last baby, and the doctor said it was postnatal depression – how should it be treated?

After having a baby, about 50% of women experience postnatal blues with fleeting low mood and tearfulness lasting for 1–2 days. It most often occurs on day 3. Though it can be uncomfortable, it is brief and gets better spontaneously.

More serious is postnatal depression, which can occur in about 1 in 10 women, most frequently in the first month after delivery. Postnatal depression lasts longer and can without treatment go on for several months. It is more likely in older mothers, those who were separated from their father when they were young, where there were physical problems in the pregnancy and around the birth of the baby, and in those having a past history of depression. Most postnatal depressive illnesses last for less than a month (even without treatment). If it lingers, it is important to get it treated promptly.

The treatment is as for any other depressive illness, with the proviso that, if your wife wants to breastfeed the baby, the drugs are chosen with special care. The drugs that we have most experience with during breastfeeding are the long-established tricyclic antidepressants like doxepin (Sinequan). Fluoxetine (Prozac), a newer antidepressant, has also been very widely used.

It is, of course, very important not just to be prescribed drugs but to have plenty of ‘talking time’, and as much help available for her and the baby as possible. Postnatal depression is likely to be difficult for you as well. Sometimes it is very helpful to have a limited amount of therapy and guidance as a couple.

Can postnatal depression recur after another pregnancy?

 Yes. There is an increased risk of depression following subsequent pregnancies (about twice the average risk), but it is by no means inevitable. It is important to remember that having been depressed in the past will almost certainly mean that the mother will realise what is happening much faster than during the first illness – as will family members. The family doctor and health visitor will also be alert for any changes of early depression, and treatment can be started quickly.

 8.4 Menopause

 Does the menopause cause depression?

No. There is a widely held folk belief that it does, but careful review of research shows that the menopause itself does not cause depression. However, around the time of the menopause (average age 51) there are several very big life changes and adjustments that may be happening. This is the time when children are leaving home. Remaining children are often (potentially) difficult teenagers. Parents, and in-laws, may be ill and need care or may die. Husbands may be ill for the first time. There may be the threat of redundancy. Growing old is, perhaps for the first time, a tangible reality. The fifth decade is a time when both men and women tend to review and reflect about what they have done with their lives. It can sometimes be a time of regret. It is these sorts of changes and losses that can lead to depression rather than the actual fact of the menopause. Who gets depressive illness?

Can HRT help depression that occurs around the time of the menopause?

Yes it can. HRT will not act as an antidepressant, however, but can be expected to help decrease some of the unpleasant symptoms that can occur during the menopause, such as hot flushes and night sweats. Sleep is sometimes seriously disrupted with night sweating, and this will tend to make coping with low mood much more difficult. Sleep that has been disrupted by menopausal symptoms can continue to be disrupted even when the changes of the menopause are settled – a pattern of poor sleep can be established. It is important to try and treat this early.

8.5 Victims of violence

My sister says that her husband is violent towards her. I can’t understand why she stays with him.

Domestic violence accounts for about a quarter of violent crime within the UK, but only about a third of incidents are reported. Domestic violence is the leading cause of injury in women aged 20-44 years. The rate of violence is the same in all the social classes. About two women a week are killed by their partners in the United Kingdom. It is a very serious problem. Violence tends to escalate, and worsen, as long as the victim stays with their aggressive partner. Sadly domestic violence does not get better with time.

Women are most at risk of being victims of domestic violence when they are pregnant.

There are many reasons – not least practical ones – for staying with a violent partner. It may be very difficult to get away from the home; there may be no spare money for taxis or train fares. It can be extremely difficult to find accommodation at very short notice for a mother and perhaps two or three children. There is always a very real fear of reprisals for the woman who escapes.

Victims of domestic violence tend to become ‘dis-empowered’. A situation develops which is very like that which exists between a prisoner and a jailer. The victim is undermined and gradually loses the necessary energy and self-esteem to stand back from the situation and see what is really happening. Violent men are often very vulnerable and may come from abusive backgrounds.

Their vulnerability can produce a feeling of pity and caring from the victim. There is a belief on her part that she can change him if she tries hard enough. Violent men can of course change, but they often need considerable help and support to do so. It is too dangerous a problem to try and address alone.

What could my sister do?

She could encourage her husband to seek help. Groups such as ‘Men Against Violence’ may be a good starting point. Domestic violence is often linked to alcohol abuse. This will need to be addressed. It is not helpful to keep the problem secret. Reporting domestic violence to the police may well be the first step in tackling and dealing with the problem. The police have made great efforts to change the way they deal with victims of domestic violence. Women are now treated much more sympathetically when they report domestic violence than even just a few years ago. If violence is continuing and the perpetrator seems unable or unwilling to accept responsibility for what is happening, it is essential that any victim of domestic violence has an emergency plan in place, which would enable her to leave the home at very short notice. This may include keeping some spare cash (‘getaway money’) aside, keeping a second set of car keys available, having access to a friend or relative for shelter, and having the telephone number of Social Services readily available. The Social Services Department can provide a ‘safe-house’ for battered women and their children in an emergency. The addresses of safe-houses are kept confidential, and change, for obvious reasons.

Finally for a victim of violence, having somebody who will listen, and encourage them to try and alter the situation and seek help, will be of enormous importance. Being angry and condemning the violence does not help either the victim or the perpetrator of violence to work for change.

I wake up at night with horrible dreams and am very irritable since I was mugged. What help can I get?

Any violent experience to ourselves is very shocking. It’s as if the safety of our personal space has been invaded. Broken sleep, recurrent thoughts about the assault, mood changes and irritability are all a normal psychological reaction in these circumstances. Victims may irrationally blame themselves after an assault (‘If I hadn’t said that, he wouldn’t have done it’) and self-esteem is lost. There is shock and humiliation at our lost safety or self-respect.

These understandable feelings can pass on their own with time but it does seem that specialised counselling helps. The Victim Support Scheme (VSS) is a highly recommended national charity with branches in many areas. Their brief is to support anyone injured as the result of a criminal act. They work free with trained volunteer counsellors who can visit people at home. They can also assist in workplaces with staff support schemes.

8.6 Men

Do men get the menopause too? My husband is not quite himself now he’s nearly 50. He keeps mentioning his age and says he looks old.

Men may not visit the doctor with classical symptoms of depression and therefore it may go undiagnosed for some time. The ‘male menopause’ is something you’ll see discussed more in newspaper articles than in medical journals. Men do not undergo the same dramatic step down in hormonal function that women do, but they do go through the same life changes in middle age as women do. Children become independent and leave home, leaving the domestic nest empty. Younger people at work may be coming up fast on the inside lane, maybe making them feel that they have got as far as they can in their careers. Their life roles might be changing in subtle ways, and they realise that they are not indispensable. They may start to experience ill-health (minor or major) in middle age for the first time. None of these factors in themselves is overwhelming, but all can contribute to a perhaps subtle drop in self-esteem and loss of vitality. There is ongoing research into male hormones, and how they affect mood. It is na exciting new area.

What can I do about it?

One way of looking at this is to consider that he has the choice of using his interests and skills for ‘recreation’ or of just stagnating. Encouraging him to develop new interests and hobbies can be a great help. Perhaps at your age the children will be leaving home, and for the first time for some years he will find that he has time on his hands. Spending time together on interests that you used to share, things that you had in common when you first settled down together, is a good start.

8.7 Elderly

My granny is 89, and has been in hospital for months since breaking her leg. She seems very quiet and low, not her usual self at all, and hasn’t got back on her legs yet. What can be done?

Depression can affect up to a quarter of hospital medical patients. The probable causes are many: the upsets in their daily routine, pain, loss of social contacts, and the effects of complicated medication. This isn’t always easy to spot, as they tend to be very uncomplaining, and the doctors and nurses might not notice that someone has lost their spark.

This can sometimes explain why an older person is slow to recover after an operation, or slow to get moving after a fracture. Start off by discussing this with the Ward Sister or Doctor. Elderly people can respond brilliantly to medication for depression.

Isn’t sleeping poorly and feeling low just part of getting old?

Depressive illness in older people is common and easily overlooked by family and doctors. About a quarter of over 65-year-old people seeing their family doctor will have depression.

Maybe 1 in 3 people living in residential homes are depressed. The illness can be missed because the distress is expressed in bodily complaints, rather than the experience of low mood.

Reduced sleep, weight loss, poor appetite, constipation, mood swings and general slowing down can all be part of the subtle picture of depression in an older person, and many of these symptoms may wrongly be ascribed to growing old. Picking this condition up in older people is important because treatment can improve the quality of life immensely.

8.8 Bereavement

Our grandad has been very low, since he was widowed. He keeps talking about moving to the seaside where he grew up, but that was 50 years ago and he won’t know anybody there. We don’t think this is sensible.

Nor would we, but it is not uncommon for elderly depressed people to make unrealistic or romantic plans, for example to return to their home town to look up old friends. They can disregard the obvious practical difficulties (including their own infirmities) and are somehow hoping to turn the clock back to a golden past – which perhaps never existed. Major life decisions such as selling up and moving house must be discouraged when someone is bereaved. If possible, delay decisions about major changes for at least a year after bereavement, possibly even two. Try to steer round the subject – ‘Until you are better, Grandad.’

Question: My father is 76 and has become very quiet, withdrawn and forgetful since mum died. Sometimes I find him in tears. Is he getting senile? What can be done?

Depressive illness in the elderly can be difficult to spot. A depressed elderly person can appear to have a dementing illness. If the depression is treated, the ‘dementia’ fades. On the other hand, dementia can first show itself with low mood. Finally, your father’s poorer functioning could be a result of his grieving process. Bereavement can be all-consuming and, at times, difficult to distinguish from a depressive illness. Your father needs a review by his doctor. It would be very helpful if you could attend too, in order to explain the changes you have seen. Once it is clear what is causing this, he can then start treatment.

8.9 Post-traumatic stress disorder

After a bad road traffic accident, I am physically fine, but am depressed and very tense. Is this PTSD?

It may be. Post-traumatic stress disorder (PTSD) can occur when somebody is exposed to a traumatic event outside the normal range of human experience. That experience would cause suffering in almost everybody. The response that occurs includes intense fear and a feeling of helplessness. This can lead on to persistent ‘replays’ or flashbacks of the incident with recurrent nightmares, very intense psychological distress and the physical symptoms of extreme anxiety, when the person is exposed to any situation that might resemble or remind the person of the trauma.

Because these flashbacks are so unpleasant, the person often goes to great lengths to avoid any of the situations that cause them. People with PTSD are described as being ‘hyper-aroused’. They are in a state of high anxiety and alertness. They easily become startled, their sleep is disturbed and they tend to be hyper- or overvigilant about their surroundings. These symptoms cause a decrease in the person’s general ability to cope.

Depression commonly occurs as a consequence of the PTSD. Can it be treated?

Yes. PTSD responds to a variety of treatments. It usually responds best to cognitive behaviour therapy. The person is encouraged to relive the experience in a graded and safe way, while at the same time taught techniques to relax. Learning more about a process of the illness and the way in which stress affects the body can make unexplained and frightening symptoms much more manageable. People suffering with PTSD quite frequently become depressed and this will need treating, perhaps with medication, in its own right. Some antidepressants are prescribed in PTSD, not necessarily to treat depression, but to control symptoms of anxiety. Antidepressants have the added advantage that they are not addictive, whereas some medications that control anxiety very well (like Valium and its family) are addictive and cannot be used for long periods.

Sometimes people suffering from PTSD try to blot out their anxiety by using alcohol. This tends to compound the problem since, after initial relaxation with alcohol, there will be a rebound of very unpleasant anxiety, which will make the situation worse.

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