July 2000

Lecture – Dr. Martina Corry, Consultant Psychiatrist, St. Patrick’s Hospital 

Depression:  What is it?  What can we do about it?

The problem is the wide definition of the word “depression” which is often used to indicate a transient “down” feeling.

Clinical assessment:

The doctor must review the patient’s concept of depression.  Then the doctor must assess and classify it accordingly.

• Reactive depression. This relates to loss.  This includes the grief reaction but it differs in that grief is experienced in all societies and remains classified within            the parameters of the society and outside the classification of depression.
• Organic depression. This is associated with physical illness.

Example:- Flu virus at Christmas resulted in a mild depression.  Effective treatment was to eradicate the virus.  When a patient presents with depression, it is necessary to check out their physical health.  Cancer can often be masked by depression.

• The person has no control.  This is an illness where the neuro chemicals in the central nervous system are not working properly.  This has two categories:-
• Unipolar

Men                 –           3%

Women            –           6-9% women

• Bipolar

1% of population both in Ireland and world-wide.

The formal diagnosis for Depression has only arisen in the last 30 years.  It is the research work that has provided the basis for the diagnostic criteria, DSM IV. Two criteria are that the person must have a depressed mood or loss of interest or pleasure for two weeks and the person must also experience 5 other symptoms:-

• Loss of appetite resulting in weight loss (sometimes weight gain occurs). The neuro chemicals are affected by altered eating pattern.
• Sleep disturbance. In the case of Unipolar, the tendency is to wake about 4.00 a.m.  Over sleeping happens more frequently in Bipolar but in this case, it is that the quantity is increased but the quality is reduced.
• Energy disturbance – anxiety resulting in nervous energy.
• Psycho-motor retardation or agitation. This applies particularly when chemical imbalances exist.  Physical appearance shows slowed person.  The energy system, similar to a battery, is flat.  Spontaneous movements are affected.  This applies particularly to those who have a chemical imbalance.  Often, the patient will be seen to be staring into space.  This can be frightening.
• Worthlessness/guilt (imagined). The reassurance of others may be of no benefit.
• The person is forgetful and easily distracted.  The person quite often thinks they have alzheimers.
• Recurrent thoughts of death or suicidal thoughts and in some cases going as far as to make plans. Again, this is mainly biological factor.

OUT  RULE:

• Organic factors (Review lung cancer particularly)
• Un-complicated grief
• Psychotic disorder i.e. schizophrenia. NB:  These can have a co-existent depression which must be treated separately.

 PREDISPOSING FACTORS

• Chronic physical illness can trigger an ‘illlness’ depression.  What happens is that the ‘pain signal’ to the brain activates the brain response to lower energy.

• Psychoactive substances which cause depression:  The main one is alcohol (legal) which remains in the blood for 72 hours.  The illegal substances include heroin, cocaine, etc.
• In the case of Separation/Divorce – the central nervous systems responds to      what goes on in our lives.  Universal finding that those in separation/divorce   category are affected more (both physically and mentally).  This also pertains to employment status.

ASSOCIATED FEATURES:

• Anxiety
• Obsessive ruminations
• Recurring intrusive thoughts
• Panic attacks/phobias
• Disturbance of perception and hallucinations e.g. a person who feels so guilty that they believe they should be in Mountjoy and not St. Patricks.

FOR TREATMENT:  THERE MUST BE AN UNDERLYING DIAGNOSIS.

EITHER:                    BIOLOGICAL

                                    OR

                                    PSYCHOLOGICAL/EMOTIONAL

The synapses in the brain need to be normalised.

MEDICATION HISTORY:

1. Trycyclics – these were the first drugs to be introduced (1950’s)
2. MAOI’s – these worked well but are now off the market (particularly successful for anxiety based depression)
3. SSRI’s (Focus Seratonin)
4. SNRI (Seratonin and Noradrenaline). Efexor includes these and others.

Personal note:  I have taken on different occasions all of these drugs.  2016 “Cocktail includes Efexor Lithium Zanax Zimovane

Those with a biological illness:

Lithium is prescribed.  It is not known how it works but has a 70% success rate.  Anti-depressants can be added to this.

Electroplexy

This is used for 10% of severely depressed people.  It works – it is deemed life saving.  It is not known how it works.  No doubt future generations will not look favourably on how it was used now and in the past.

Light Therapy:  This only applies to those who have SAD.  It is of no benefit to chemical or other classifications of depression.

Psychotherapy is only beneficial to those who have a non biological illness.

• Analytical (Freud). This is used less than in the past
• Behavioural.  This is very successful in regard to phobias, psycho-sexual problems, and anxiety
• Cognitive.  The aim is to change repetitive thoughts and assisting with life coping skills and  cases of  post traumatic stress
  • Grief
  • Marital/family counsellors

Anxiety/perfection character traits cause greater tendency for depression.

THE THRUST OF DEPRESSION IS TO ACHIEVE REMISSION

The aim should be a normal life.  Bipolar and Unipolar depression is intermittent.  The reason to keep taking the medication is that depression lurks like a thief in night.

The question is does the person concerned want to take the gamble. 

To stop medications mean manic episodes High or Low.

August 2000

MICHAEL CURRAN – AWARE MEETING ST. PATRICK’S HOSPITAL

Dr. Curran is a Consultant Psychiatrist in Derry Hospital, Northern Ireland

Specialty:  Social Anxiety Disorder

Some people are more shy than others.  This can give rise to alcoholism and other problems at a later stage in life.  SAD commences in adolescence and is responsible for a lifetime disability.  Early recognition therefore is beneficial.

The person has a fear of scrutiny in social situations.  The incidence is as high as one in twenty over a lifetime period.  It is a ‘disease in disguise’ and is often labelled as depression.

Traits:

• social phobia (have to force themselves to do engage)
• suicide prone
• depressive
• internal commentary of what others are thinking about them
• embarrassment
• tremor
• hate signing cheques in public
• telephone problems
• eating in public places
• withdrawal/shyness within school confines yet one to one contact is no problem           (this relates to a fear of being watched)

The problem is related to seratonin levels.

What can occur?

• substance abuse
•  depression
•  severe anxiety

Things to watch out for:

• children who are afraid of animals
•  fear in lifts
•  thunder
•   flying
•   children afraid of meeting others at school

Outcome Signs:

Avoidance or endurance of distress

Tend to quit out of school if possible, their friends and ultimately their livelihood

The major fear is being evaluated e.g. exams and this causes a spiral to anxiety levels.  The thought processes go out of control which in turn lead to physical symptoms like trembling hands.

Similar to MS, if not identified, it is progressive (not regressive).  It can result in co-morbid states.

The first appointment with the patient is the most important.  The key is what leads to the presentation.  It can be the separation from a parent or another traumatic event.  What might arise is the patients fear that the teacher may ask them a question during a class period?  Need to watch out for COD’s and body dysmorphic disorder.

Drugs:

SSRI’s, MAOI’s i.e. pharmacology and Cognitive Therapy.

Options:  Exposure Therapy.

            –           Social Skills (Aware)

            –           CAMS (deals mainly with men).  Includes weekends away.

            –           Rational Self Talk

            –           Distraction techniques

Note:  Today due to the hectic way of life, people sleep 1.5 hrs less than they would have 15 years ago.  This is possible explanation as to why people sleep the first week of their holidays.

Do not give up medication until you are absolutely sure everything is okay.

This is a life long condition.

NOVEMER 2000

AWARE MEETING AT  ST. PATRICK’S HOSPITAL

Aware sponsors a number of projects particularly in the area of Genetics.

Carmel Kealey, Genetics Department, Trinity College Dublin

Basically scientific data.  No one gene causes bipolar depression, it is spread over a variety of genes.

Dr. McKeon – ‘trying to find a blade of grass in a field’.  The Human Genome Project will impact significantly, but it over years rather than months.

Note:  People taking Lithium must not take steroidal anti-inflammatory drugs e.g Ponstan, Bruffen – Notify GP (This is not stated in MIMS).    While on Lithium, it is necessary to keep the sodium levels at an equilibrium.

Dr. Pat McKeon.

10 years ago – Aware was involved in a national survey of 1500 people.  The aim was to get the general public’s opinion about depression.   Findings revealed that in general the public gave a positive response.  Young men tended to be less empathetic but as they aged, married, experienced more life events, their attitudes softened.  The public were asked the question – Who can help?  While 80% in the UK said their GP, in Ireland there was only 17%.  They then carried out as smaller study of 70 people in the Dublin area.  They got the same result i.e. 17%.  The problem was not the care element.  80/85% saw this to be good.  Yet, men particularly, said they would not consult their GP.  Basically, they regarded depression symptoms as just part of everyday life.

Aware encourages GP links.  They provide lectures and guidance for general practitioners.

10 years later, it was decided to have a follow up study to measure any significant shifts.  They reviewed the perceptions of causes of suicide.  The general consensus was that people who suffer from depression are not mentally ill.  21% agreed with the statement that they would not employ someone with depression.

What is interesting is that the ‘Don’t knows’ have increased.  This is consistent.  As people become more educated, it is less easy to be decisive.

43% of the farming community linked depression to a genetic factor but this can be expected.  Farmers exist in a community and often have each other’s family history.

The difference of significance:

NOW:  76% said they would approach their GP.

The significance of this is that the gates are open to have depression treated and acknowledged.

SUICIDE:

People’s perception.  They disconnect the depressive element from the facts.

90% of Suicide surveys always indicate a depressive factor.

IN ORDER TO ADDRESS SUICIDE:

We must get people to link depression and suicide.

Unemployment/financial/family difficulties are not the main causes.  If they are, it is probable that the person has had a depression/depressive episode.

Young men who commit suicide.  The numbers have increased significantly but it is interesting to note the increased alcohol levels.

FINDINGS: Yes, it is difficult to change public opinion BUT if you focus on a particular area, changes can be made.

Several years ago, AWARE ran an advertising campaign listing symptoms in a TV advert presented by Anne Doyle at prime times.  GP’s initially hassled but the overall outcome is a better service.  Protocols have been put in place.  It is the use of the consumer concept to shape the producer i.e. the GP.

Years ago Suicide was rare in general practice.  A GP would probably encounter one every 5 years.  Now this has changed and per consequence GP’s are more proactive prescribing anti-depressants etc. having had more exposure to the downside of depression.

A recent survey indicates:

7.3% in the workforce are actually clinically depressed whereas those visiting GP’s waiting rooms amount to only 6.4%.  For every depressed man there are 8 women who are depressed.

No findings that say clinical depression is on the increase.  However in the case of mild depression there is a slight increase.  This, in the case of clinical depression, would possibly indicate the genetic factor.

The word depression is not really sufficiently descriptive.  Depression is more like a physical illness.  This needs greater emphasis.  There is more stigma attached to Bipolar.  In relation to Unipolar depression, people tend to reflect their own experiences, when you state you have depression.

The diagnosis of Bipolar is extremely difficult.  Cannot be done in a consultant appointment.  Minimum requirements is that you need is a family history.  It would not be possible for a psychiatrist or GP to sift out the information from a patient at a visitation.

Religion –  any impact?

No.  Once the person gets depressed, nothing penetrates to assist.