Understanding Depression

Depression is a common mood disorder affecting one in five people in Scotland at some point in their lives. Many people who experience depression will not seek help. This is largely because they mistakenly believe that depression is a sign of weakness, or an inability to cope, rather than realising that depression can be treated.

Whilst depression will affect everyone differently, typical signs of depression can include:

  • persistent sadness
  • feelings of hopelessness
  • thinking badly of yourself or not liking yourself
  • feeling lonely or miserable
  • feeling anxious
  • not looking forward to things or enjoying things that you usually do
  • feeling guilty or bad or getting easily annoyed
  • eating too much or too little
  • not sleeping well
  • lack of interest in sex
  • poor concentration
  • not looking after your personal appearance
  • unexplained aches and pains or stomach problems
  • suicidal thoughts in severe cases

The majority of people experiencing depression will recover with the right interventions. The most important step for people with depression is to reach out for help and support.

With the right treatment and support, most depressed people make a full recovery.

Action on Depression website [external site] This Scottish charity offers information for the public about the treatment of depression and details of the support available.

NHS Choices [external site] The NHS Choices website offers a description of the warning signs of depression, an online test, and help for sufferers of the illness.

INTRODUCTION

Recent figures suggest that as many as 500,000 people in Scotland may currently be experiencing symptoms of depression. Depression is one of the most common reasons for people consulting their GP in Scotland. Often people experiencing depression also experience feelings of anxiety as well.

The Information and Services division of the NHS revealed that one in ten adults are now taking anti-depressant medication every day to combat depression. Since 1999-09 the number of drugs being prescribed by GPs in Scotland has increased from 2.5 million to 4 million items.

Concerns have been expressed by politicians and health experts given the challenges of the current economic climate.

These concerns are supported by the Scottish Association for Mental Health whose recent study showed that people affected by the credit crunch are eight times more likely to suffer depression than before.

The exact cause of depression is not known and is thought to be a mix of contributing factors. For some people it can occur for no apparent reason; others can pinpoint a trigger such as a difficult life event, a bad time in their past or some sort of trauma. It appears that in some families there can be a genetic element.

Whatever the cause, it is important to remember that depression is as recognisable an illness as cancer or diabetes. Stigma still exists as an additional barrier to people seeking help, but the earlier people access support the sooner they can regain control and move on with their lives.

No individual is predestined to develop clinical depression, but it is true to say that some people may be more vulnerable to it than others. It is important to be aware of our own personal risk factors so that those of us who may be vulnerable can educate ourselves, be attentive to warning signs and take steps towards recognising and preventing recurrent episodes.

Longer term stress is known to be a major factor in the causes of depression. Taking action to reduce and control stress in our lives will reduce this risk considerably.

Specific issues:

Postnatal depression With respect to the prevalence of depression during the transition to and following motherhood, parents and health carers need to be alert for signs of depression, and to ensure that mothers and their babies receive the full care and support they need. More information about postnatal depression is available on:

NHS Choices [external site] This website offers information about depression during pregnancy

Action on Depression [external site] More information about post natal depression can be found on this website, along with links to organisations that can help.

SAD Seasonal Affective Disorder, or SAD, is a form of depression which develops in the autumn and improves in the spring. It is thought to be caused by lack of natural light in winter. For information around seasonal affective disorder, visit the SADA.

DESIRED OUTCOME

  • Reduced incidence, prevalence and burden associated with depression

CURRENT EVIDENCE

Actions which can contribute to reducing the incidence and prevalence of depression and anxiety include reducing factors known as ’risk factors‘and increasing factors known as ‘protective factors’.

Risk factors can include a history of depression, physical illness, prolonged stress, social isolation, unemployment, financial problems, excessive use of drugs and or alcohol, and significant loss or trauma.

Protective factors can include having supportive relationships, being connected to the local community, being emotionally resilient and having good physical health.

Breathing Space Scotland [external site] This website offers detailed information about the risk factors associated with depression.

Action on Depression mood menu [external site] The mood menu on the Action on Depression website suggests a range of activities which can increase protective factors.

RECOMMENDATIONS

Depression is mostly treated in primary care. This means that GPs are generally tasked with sourcing the most appropriate treatment for the person and their on-going care.

Depression can be treated using a variety of interventions and treatment options. These may include a combination of antidepressant medication and or psychological therapies such as Cognitive Behavioural Therapy (CBT), guided self-help, and advice on changes you can make to your lifestyle that will help you, such as changes to diet and levels of physical exercise. The type of treatment or combination of treatments that suits the individual will depend on personal preferences, general patient health and on how severe the depression is.

NICE has identified a model of good depression care, in consultation with clinicians and patients based on a combination of medication, talking therapies and self-help.

For some patients, particularly those with more severe depression or where treatment is not successful, more specialised care, including inpatient care, may be needed. NICE guidelines include:

  • recognition of depression, in both primary care and hospitals, with particular attention to high-risk groups. This includes patients with a past history of depression, long-term illness or disability, or other mental health problems such as dementia.
  • patient preferences, and the experience and outcomes of previous treatments, should be considered when deciding on a treatment.
  • patients should have access to information about treatments, self-help, and support groups.
  • for people with mild depression further assessment is required, usually within two weeks. The patient may recover without intervention. Antidepressants are not recommended for the initial treatment of mild depression. Guided self-help, such as computerised cognitive behavioural therapy, should be considered.
  • For people with mild and moderate depression, psychological treatments such as CBT, problem solving therapy or behavioural activation should be considered. The SIGN Guidelines [external site] give advice on the non-pharmaceutical management of depression
  • treatment with antidepressant drugs. Selective serotonin reuptake inhibitors (SSRIs) should be considered over tricyclic antidepressants because of better safety and fewer side effects. All patients should be informed that withdrawal symptoms may occur when stopping, missing a dose or reducing the dose.
  • for people with severe depression, a combination of antidepressants and individual CBT should be considered as combining the treatments is more effective than using them on their own. This approach has also been found to be most effective in patients who are resistant to treatment with medication.
  • patients should give meaningful and properly informed consent to treatment, in particular if they have more severe depression or are subject to The Mental Health (care and treatment) Scotland Act2003
  • there should be a clear agreement about all patient care. This should be shared with the patient and their families and carers.

Physical exercise The recent UK Department of Health publication ‘At least five a week: evidence on the impact of physical activity and its relationship to health’ states:

‘People who lead an active lifestyle over several years have a reduced risk of suffering symptoms of clinical depression. Physical activity is effective as a treatment of mild, moderate and severe clinical depression. It may also help people with other mental illnesses’.

DoH, At least five a week: evidence on the impact of physical activity and its relationship to health’, 2004 [PDF 1.9MB]

Antidepressants There is no shortage of evidence showing that antidepressants are effective in treating depression. Different studies quote different figures, but broadly speaking around 60 per cent of people with depression will improve when taking an antidepressant.

Interestingly, around half these people would improve if they were unknowingly prescribed a dummy pill or placebo and this is higher than if they had received nothing at all. The placebo effect occurs with many other types of medicines including painkillers. Placebo medicines can only be prescribed to people who have consented to a medical trial and so are not used in daily practice.

Action on Depression [external site] offers information about common antidepressants, potential side effects and other frequently asked questions.

Psychological therapies The National Institute of Clinical Excellence (NICE) has identified a model of good depression care, in consultation with clinicians and patients. It is based on a combination of medication, talking therapies and self-help. There is a significant amount of evidence demonstrating the effectiveness of CBT and other psychotherapies, usually in combination with medication.

CASE STUDIES

Personal experience of depression [external site]

Depression and help through a combination of CBT, medication and exercise.