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Understand and Prevent Depression

(41) Depression

Teen Depression: Signs, Symptoms and Getting Help


Going into hospital

I have been referred to a hospital specialist. I am not keen to see them. Do I have to go?

No, but remember that NHS resources are scarce. Your doctor will not refer you to a specialist lightly. Do go to the appointment if this has been arranged. If you are not clear why your doctor wants to refer you, do ask.


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(42) Depression



Electroconvulsive therapy (ECT)

When is ECT used?

ECT is still the strongest and most powerful treatment we have  for severe depression. It can and does save lives. Sadly, it has had a very bad press. When ECT was introduced in the early 1940s, it was undoubtedly overused. It began because some psychiatric patients, who also had epilepsy, seemed to do better than similarly ill patients without epilepsy. Medically induced fits were then shown to help patients with severe depressive illness. At that time there were no antidepressants or tranquillisers - just sedatives. People were desperate to find an effective treatment.

Then it was given without anaesthetic, which made it look a frightening and fierce treatment. Memories of this (plus reminders through the media) perpetuate the bad old image of ECT. ECT is now given under strictly prescribed guidelines and is very different from its original practice.

ECT is given to people with severe and life-threatening depressive illness, and it includes those people who are not eating or drinking adequately, or who are judged to be a serious suicide risk. Some depressive illnesses cause abnormal thinking - delusions (or false beliefs). This type of depression responds well to ECT. ECT is sometimes recommended for people with resistant depression (an illness not improving after two full courses of antidepressant medication). It may be given when the side-effects of medication are risky. This may happen in the elderly or frail. It is sometimes used in serious postnatal depressive illness, because it is fast and effective. It is essential to try and gain improvements quickly in this situation. A sick mother cannot bond with her baby.

If ECT is recommended it does not mean that you are potentially incurable and that the doctors are suggesting a ‘last ditch treatment’. I am worried that I will be asked to have ECT when I am in hospital.

Can ECT harm - or even kill you?

ECT is safe. It can be safely given to people with other illnesses, and does not clash or interact with medication. It is particularly effective in severe depression. There is no evidence that it can cause brain damage, and does not affect your intelligence or personality. The risk of dying during the procedure is about 2 per 100,000 procedures - this is the risk of having a general anaesthetic; ECT itself does not itself pose a danger. There is good and strong evidence that it prevents suicide.

 What happens during ECT?

You will also be asked to sign a consent form (because an anaesthetic is to be given). A relative cannot consent for ECT on another person’s behalf. Prior to each treatment, you can have nothing to eat or drink for 5 hours. This is standard preanaesthetic practice - for all anaesthetic procedures, not just brief ones like ECT.

You will have routine blood tests, and a physical examination (as for any other anaesthetic) before treatment. The treatment involves having a carefully controlled current of electricity passed via both temples while you are fully anaesthetised (totally asleep and totally muscle relaxed).

The amount of current used is low. The anaesthetic is brief – a matter of a few minutes. The current causes a brief and controlled seizure (or fit). The exact mechanism by which ECT works is not fully known (but then we are not sure how may drugs work either), but it does seem to increase the sensitivity of the brain to its own neurotransmitters. After the treatment, you sleep for perhaps 5-15 minutes. You may be a little drowsy, but you usually awake longing for a cup of tea within 30 minutes of treatment.

Are there any side-effects of ECT in the short term?

Yes. Headache is common – it usually is short-lived and responds to a simple analgesic like aspirin or paracetamol. There may besome muscle aches and pains - this is an effect of the muscle relaxant agent given with the anaesthetic. It is most prominent during the first or second treatment and will go away. Memory is usually fuzzy for a time just before treatment and just after it (as it would be with any other anaesthetic).

Are there any long-term effects of ECT?

Almost certainly, no. This is a question that has been widely and very carefully researched both in Europe and the USA. It is still debated. If damage does occur, it is a result of the anaesthetic not of the actual seizure. People who were given very long and frequent courses of ECT in the past may show some memory impairment. ECT given as it is today has given rise to no discernible problems with memory. In fact, overall, of people who are equally severely depressed, those who have ECT do better than those who do not (if you test their memory some years later). The memory problems that have been reported are very difficult to evaluate. People who are depressed enough to warrant ECT generally have poor concentration – if you haven’t taken in information it will not be there to retrieve. It may seem that you have forgotten something but in fact the information wasn’t processed. Another complicating variable is that of medication.

Some antidepressants are sedating and contribute to a feeling of poor memory.

How many ECT treatments are necessary?

This depends very much on the individual’s response. The average course of ECT is about six to eight treatments. Treatments are usually given twice weekly. You may start to feel better after the first treatment – perhaps sleeping better that night, or there may be no discernible change until after the second or third treatment. Some people need only two or three treatments, others need up to 12. Treatment will be stopped when the rate of improvement levels out.



(43) Depression

The Truth about Depression BBC Full Documentary 2013


Leaving hospital

What happens when I leave hospital?

Following discharge from inpatient care, a letter is sent to your doctor detailing what treatment and medication you have had, and the follow-up arrangements made, e.g. date of the next outpatient appointment. Arrange to see your doctor in the week following your discharge, for a review. You will also need to get a new prescription for your tablets. You are usually given a week’s supply of medicine from the hospital. It is worth taking the medication with you to the surgery to show your doctor - sometimes a hospital letter is delayed. An awful lot of tablets are white - the exact names and dosages will be needed.

Day care may be suggested - this may be anything from a morning a week at the hospital to 5 days per week depending on need. Day hospitals offer a wide range of treatment from group and individual work, to creativity sessions and anxiety management courses. A wide range of health professionals are involved in providing treatment in a day hospital.

When you are well enough, treatment will be completed in the outpatient department - a visit to the clinic at lengthening intervals, until your care is then transferred back to your doctor. Fares to and from the day hospital or outpatient clinic might be refundable - do ask.

 A CPN (Community Psychiatric Nurse) may visit you at home. What does a CPN do?

CPNs review your progress, monitor treatment and sometimes do specific tasks, perhaps helping you gain confidence leaving the house. They may visit you if you have recently come out of hospital, or give regular medication to someone who has longer term difficulties, such as a psychotic illness. CPNs may have a wide range of skills, and often have a variety of roles. Some will be ‘nurse therapists’, expert in providingtreatments, such as cognitive behaviour therapy, relaxation training, or basic counselling. They may also have responsibility as ‘case managers’, coordinating community care (medications, benefits, day hospital, drop-in centres), enabling people with more severe illness to manage at home.

 What is a care plan?

My granny is in hospital and I’ve been invited to attend a case conference about her. Every patient who is admitted to hospital will have a multidisciplinary care plan made to meet overall medical and social needs. A key worker is appointed to coordinate care, and to seethe plan through. For example, someone might need housing improvements, home help, meals on wheels, and a supply of regular medication.

Doctors, social workers, family, psychiatrists, and nursing staff may all be involved in planning someone’s care before they leave hospital, to see that every aspect of their case has been considered. Family may be asked to attend, as relatives’ opinions and concerns are very important.

 Having time off and getting back to work

 If you are unwell with depression, it is important to know when to switch off from work for a while, as your work performance is significantly affected even if you don’t quite realise it. We describe the basic paperwork - medical certificates, or sicknotes - that you will need if you become unable to work for a short or longer time. We explain how to get help with benefits, and the allowances that are available for people with longer term illness and their carers: Statutory Sick Pay, Incapacity Benefit, Disability Living Allowance, Community Care Grants, Crisis Loans, and Invalid Care Allowances. We also mention where you can get skilled help to find your way through the complexities of the Benefits system.

After a spell of depression, it is often wise to get back into work gradually: the Therapeutic Earnings Scheme, as well as an Occupational Health Department can both be of help here. It is not always easy to know what to say to people at work, and we discuss who to tell.

Sickleave and sicknotes

 How do sicknotes work?

For a short break of up to 1 week, you’re entitled to self-certify. Your workplace will have a supply of self-certification forms (SC2). If you need longer than a week, your doctor will give you something called a Med 3. This states your illness (perhaps in vague terms as we’ve mentioned elsewhere) and how long you’re likely to be off sick. This can be a Final Note if you’re going back within 2 weeks, or an Open Note if it may be longer. This can be as long as 6 or even 12 months for long-term illnesses. My employer asked me for a private sicknote when I was off sick for a few days.

 My doctor says I have to pay for this. Can they do this?

 Yes they can. You are entitled to submit an SC2 (self-certificate) for short spells of illness (less than 1 week) but your employer may wish for more details from your doctor. This seems to happen more often when people have had a lot of sickleave. Some of us suspect that this is used as a disincentive to taking more time off work, or to make life uncomfortable for employees by discouraging sickleave. Private Sicknotes cost around £10. I missed some time off work last summer and now my employers want a backdated sicknote.

 Can I get one?

 A sicknote cannot be backdated as it is a legal document, and today’s date is today’s date. To get round this, your doctor can issue something called a Med 5, to state that you were indeed ill in the past. This can be done if, say, there is a recent hospital report about your case, or from doctor records of your past attendances. This can be useful if you have moved, been in hospital, or changed doctors. Gaps between certificates can be covered in this way, if you overlooked getting consecutive sicknotes, or if (and this is not unknown) the Department of Social Security (DSS) have lostone of your certificates.

 What is a Med 4?

 This completes the set of sicknotes we’ve described. People who have been off sick for some time must be considered for an All-Work Test, to see whether they are fit for any work, not just their usual job. The DSS may ask you for a Med 4. This gives them some more information about your state of health, and may enable them to confirm that you are entitled to longer term benefits without having to have an independent medical examination by a DSS doctor. This is usually a routine request after you have been off sick for some time.

 I missed a Court attendance last week and I understand I’m in trouble. Can I be excused on medical grounds?

 Try never to miss Court cases, whether as a witness or a defendant. The Bench tends to take rather a dim view of excuses. Some people with a depressive illness may become genuinely overwhelmed by being involved in Court proceedings. However, you must take action before the proposed Court appearance. Talk to your solicitor about this, and ask them to write to your doctor requesting a medical report. They will need your written consent for this and there is likely to be a fee. If your doctor has been treating you, he or she may be able to help, if aware of yourcondition, and if you would genuinely have been unable to attend Court because of it. Retrospective sicknotes are often rather difficult to do, from the doctors point of view, with the best will in the world. Make sure your doctor and solicitor know with good warning, that you have difficulty in attending court.

 Does your doctor have to write depression on a sicknote?

I don’t want people at work to know about my problems. Sadly, depressive illness is still seen by many as stigmatising. The situation is slowly improving and more and more firms – and certainly the bigger ones – will be concerned about every aspect of their employees’ health, as they do have responsibilities towards your working conditions nowadays. Occupational Health Departments of the bigger firms will have a brief to improve stressful situations in the workplace, if this is a problem. If they are aware that an employee is under pressure, they may be able to alter things in the workplace to make life easier. So, whilst in general it is best to tell the truth, there are certain cases when it is best to use less stigmatising terms. Doctors will be only too aware of this issue, and are often quite prepared to write something vague and non-specific like ‘Stress reaction’ or ‘Nervous debility’ on sicknotes when necessary.


(44) Depression

 The Truth about Depression BBC Full Documentary 2013


Self-harm - difficult times for you and your family

Depressive illness is debilitating and exhausting for the sufferer. It also has a very powerful effect on carers and loved ones. It is difficult to go on caring and being positive in the face of continuing negativity and inertia from the person who is ill – no matter how much you love them.

It is terribly important to recognise that carers and loved ones need care too. It is vitally important that the carer cares for themselves – it is not selfish, it is essential. You cannot help if you too become ill. You need strategies to cope. If you are the person who is ill, you very much need strategies. Treatments - talking or drugs - do not work instantly. It may take 2-3 weeks before treatment starts to make an impact. You need to be able to cope day to day. Different strategies will work better at different times. Some of the suggestions that follow will help you; others may not and may even irritate you. Find what works for you and keep using it. Regular exercise may be enjoyable and helpful for some, for others it would a miserable trial. You need your own special recipe.

Motivating yourself is very difficult when you are depressed. Feeling pleasure often has to be relearned – it cannot happen to order. Experiment and try to be patient with yourself. When very depressed, coping with the day ahead is a very big challenge - tackle it in stages. Perhaps you need to plan ahead just until coffee time or lunchtime. The day ahead may seem very long if you see it as one big stretch of time. Try and have a mixture of things that may really have to be done interspersed with something that could possibly give you some pleasure. Pace yourself and praise yourself. Recognise that coping with the day, is a big achievement in itself when you are very low.

 Dealing with someone with depression

 My sister’s become a real recluse. She’s dropped out of her career, seems awfully depressed, doesn’t look after herself, and has become isolated from her friends. We help out with money when we can, but she gets resentful if we ‘interfere’. Should we leave her alone?

It sounds as though she needs help. We have all got the right to do what we want with our lives, and there is nothing to stop her leaving her chosen job or career, but this sounds more serious. If someone drops out of their chosen path and takes up some alternative lifestyle, the decision has to be accepted. However, if they are unhappy and seem ill, it is different. Is this an alcohol- or drug-related problem? If you think so, you maystart with some support and advice from your local advisory centre. These problems will affect the whole family. This does sound more like a depressive illness and may be quite severe, so first of all, keep in touch. Don’t give up on your sister, but make sure that you keep up a friendly contact. Putting too much pressure on her may be counterproductive, and people may understandably become resentful of direct advice. Occasional lunches out, and visit to the shops together; or perhaps doing things that you used to enjoy doing together when you were younger, may be a good start. Too much pressure, on the other hand may make her resentful and she may retreat into her shell.

When she realises that you accept that she is feeling low, try to look at it together with her. Understand that people with depression feel that things can never ever improve whatever anyone says or does. Quite often, no matter how fixed the ideas someone has, there is usually a small part of them that will accept that something is wrong, and they will want to do something to get better.

Maybe try leaving some leaflets about depression and mental health around (or a copy of this book). You may be able to get her to accept a visit to the doctor with you, to explain your concerns. She might use one of the phonelines for people with mental health problems. If she won’t consider medication from the doctor, she could try St John’s wort as a starter, which is an effective herbal antidepressant. At least she will then be starting to address the problem.

 A family member gets very depressed. We all love her but we don’t know how to help, she seems so low sometimes. How can we help her?

It’s really important that you help her to get started with treatment. Start out by saying that you’re worried, and get her to attend the doctor’s. Suggest she has a ‘checkup’. Perhaps have a word with her doctor. Go along with her for her first visit, if you can. It’s a big help when families do this because then we know who’s giving support, and we often get a better picture of how extensivethe difficulties are. The doctor can never disclose the contents of a consultation with a third party, however worried and helpfully concerned you are but, if you are in the room during the consultation, you can have a three-way discussion and you will then be reassured that everything has been addressed. When she starts on treatment, it will be helpful if you can encourage her to stay with the treatment until it really starts to work. Keep an eye on her medications to reassure you that she is taking them. Progress may take several weeks. If she is not getting better, or you are worried, encourage her to say so to her doctor. Different treatments may be needed if no improvement occurs. A change in her medication or a further opinion may be helpful. About 1 person in 8 or 10 may drop out from their initial antidepressant treatment owing to side-effects, and a similar proportion will need referral to a psychiatrist about their depression.

The commonest side-effect of the SSRIs is probably initial nausea and indigestion feelings. These pass off with time, so tell her to be patient, unless they are really awful, in which case her doctor’s needs to know. As a family member you are well placed to offer vital support. This can need lots of patience, understanding and affection. Don’t give up! Talk to her and listen carefully. Realise that she may be full of low and negative thoughts, which she cannot get into perspective. These thought cycles can almost seem to be catching. Depressed people can radiate gloom in an infectious way. This can be quite exhausting to the listener. Don’t be annoyed by her repeating the same worries, but do gently help her get things into perspective. If she starts to make remarks about harming herself, pay attention. Try not to panic or overreact, but do make sure her doctor knows. See that you take her along for some gentle exercise, so that she doesn’t get stuck in a rut. Make sure she does not miss out on social events - the company of other people is good treatment. If she doesn’t want to go out, ask another time, and keep asking - tactfully but persistently - until she says yes. Do not push her too hard, do not pester her, but do not give up either.

Try to get her to take some part - just a little - in her own interests: hobbies, sports, religion or pastimes. Do not expect toomuch at first, as this may make her feel guilty for disappointing you. Allow her her own space, but make sure you are closely in touch. Don’t get exasperated; if she doesn’t seem to be responding to your support, back off a little and try again later. Recognise, and reassure her, that she will get better, even if she doesn’t seem to believe you now. Recovery from depression takes a number of months with treatment, and can be quite gradual, so doesn’t become frustrated. Signs of improvement include better sleep, less early waking, less sad thoughts, and a resumption of pleasure and enjoyment in normal activities. Hope is always important. Look after yourself too; caring for a depressed person can be very draining.




(45) Depression

 Depression & Anxiety: My Story


Carers – looking after yourself too

Carers of people with depression can have a trying time.

• Remember not to take irritability and swings in mood too personally.

• Try to encourage self-care, rather than dependency on home helps, meals on wheels, for example.

• Don’t ignore any talk about self-harm but tell your doctor.

• Your relative’s personal hygiene and self-care may need firm prompting.

• Discourage plans to make big life changes.

• Look after yourself: make sure that you get support and a break from time to time.


 What can be done to help our father? He is very depressed, and seems to think he’s a nuisance to us all - he isn’t, we do love him dearly. He speaks of harming himself, and won’t see the doctor.

Depression can indeed lead to self-harm, even suicide, although this is a rare event considering how common the illness of depression is. Those most at risk of suicide are young males - in their early twenties - and then people approaching old age, who may have other illnesses to cope with. People with drink problems are also at increased risk of self-harm. There is a strong likelihood that this sort of depression will respond well to treatment and, in cases like this, it is most important that you urge him to see someone. There is good evidence that medication - antidepressants - will help him. Perhaps you should start by having a word with his doctor about your concerns. Try and take him to see the doctor for a ‘checkup’. This can be a way of making initial contact. An old person talking about harming himself is a very serious sign; however much you empathise with their loneliness and other health problems, ask for help.

 My sister says she gets feelings sometimes that she wants to harm herself. What can I do?

Many people, perhaps even most people, have at some time thought about suicide, however briefly. So perhaps this feeling is at one end of our natural range of emotions, and in itself does not mean that you have a grave mental illness. However, when someone gets stuck and has this sort of thought frequently, persistently, or they feel an impulse to act on these thoughts, it warrants urgent attention. A person who has persistent suicidal thoughts should have the benefit of an expert psychiatric assessment, on the same day if necessary.

Depression can make you quite subtly lose your natural insight, and irrational thoughts and ideas can become stronger and morereal. At the same time, people’s self-esteem and self-worth become lower, so there is less to protect you from these negative thoughts. Some people with severe depression experience thoughts about self-harm becoming so strong that they appear to be in the form of voices. That is a serious matter and someone like this is at real risk of coming to harm. They need urgent assessment and treatment.

My teenage granddaughter has started cutting her forearms. She has been quite dismissive about it. Is this dangerous?

Death by wrist cutting is very unusual, but cutting as a form of non-fatal deliberate self-harm is not uncommon. Deliberate selfharm (tablets or cutting) may occur in up to 1 in 500 of 15–24-year-olds. It is more common in girls than boys. Most people who deliberately self-harm have symptoms of psychological distress, but psychiatric illness is present in less than one-third of them.

Cutting may be a way of releasing a feeling of great tension that has built up. It could be seen as a coping mechanism – albeit an unpleasant and risky one. Cutting can become almost addictive (because of the release of tension it supplies). It might be part of other addictive behaviours such as taking alcohol or drugs. It can be part of the behaviours seen in eating disorders. There can sometimes be a background of sexual abuse. It is not an insignificant behaviour, and definitely warrants help.

 How can we help her?

Somebody who has started to cut themselves needs help. Seeing the behaviour as a symptom of distress is very important. Sometimes families can be shocked and angry when they realize a young person has been cutting themselves. Try to resist this. Cutting is usually done in an attempt to feel better. The reason for that discomfort needs to be addressed and to be taken seriously. My elderly aunt took five paracetamol tablets one evening. She seems upset and miserable, but my uncle says there is nothing to worry about. She has been low before and she gets over it, he insists. You are right to be worried. The method of harm that someone uses is some guide to its seriousness, but is not a clear guide to the intent of the person taking an overdose. Most people know that taking 300 paracetamol would kill them. Not everybody knows that five paracetamol will not kill them, so your aunt’s feelings around the overdose are all important. Whether or not the overdose was planned or impulsive, whether it was taken in relatively safe circumstances, or kept hidden, are also important factors when doctors assess the seriousness of the situation.

Anybody who has taken an overdose, or tries to harm themselves deliberately in any way, needs to be seen and assessed by a health care professional. The action could indicate a serious suicidal intent. It is very unsafe to assume otherwise.

 My sister took an overdose. The doctor who saw her in the Casualty Department said that she is not mentally ill. I think she must be to have done that.

Two-thirds of people committing deliberate self-harm are under the age of 35. It is most common in young women. Most people who deliberately harm themselves (principally by taking an overdose of tablets) are not mentally ill. However, almost everybody who deliberately harms themselves have symptoms of psychological stress. Definite psychiatric illness is found in less than one-third of people harming themselves. However, 1–2% of those taking an overdose will die from suicide in the following year.

Deliberate self-harm is usually a measure of acute unhappiness or frustration and it is a potent way of communicating distress to the people around. Very often the overdose is taken in the setting of drinking alcohol (and sometimes taking street drugs). Alcohol and street drugs will affect judgement and increase vulnerability. Deliberate self-harm is usually impulsive. Deliberate self-harm is usually precipitated by stressful and difficult events and is described as ‘situational stress’. These events have usually occurred in the days or hours prior to the overdose (not weeks or months before). In about half, there will have been a major row with a partner or family member. There might be conflict with the police and distress of forthcoming proceedings in court. There might have been loss of a job, difficulties with money, problems with children, intolerable problems with housing. There is a big link with unemployment. There may be many, many problems, but not definable mental illness.

 What can I do to help after her hospital assessment?

Take the problem seriously. Encourage her to seek help. Encourage her to see if there are any changes that can be made, or at least work towards, that will make her situation more bearable. It may be that the crisis that precipitated the deliberate self-harm is now over. It will be important to see if any everyday practical difficulties with living could be tackled and made easier – could the voluntary agencies or social services have anything to offer? A loved one taking an overdose is immensely shocking. The event can, however, be used as a starting point for important and major changes.

 Dorothy Parker, the New York poet, suffered from depression all her life. Despite two suicide attempts in her youth, she died of a heart attack aged 74. Her poems and journalism are still a joy to read nowadays, especially if you enjoy your wit acidic.


Razors pain you

Rivers are damp

Acids stain you

And drugs cause cramp.

Guns aren’t lawful

Nooses give

Gas smells awful

You might as well live.

Dorothy Parker







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