Depression

It has been said that there are as many sorts of depression as there are people suffering from it. At one time, the medical services liked to ‘compartmentalise’ depression into specific types: that coming from ‘inside’, that occurring as a response to life problems, or trauma, or bereavement etc. In recent years, this tendency seems to have reduced and doctors are now more likely to treat depression as a specific problem peculiar to the person presenting for help: that is, responding to specific symptoms and life situations rather than trying to define the disorder by type.

The word ‘depression’ is used to cover a very wide range of problems, from short periods of low mood (lasting less than two weeks) to a lifetime of mind numbing, inability to function. The great majority of cases that involve low mood will sort themselves out and do not require medical intervention. However, at any one time, between 5% and 10% of the population are suffering from depression at a level that needs support, and it is likely that 20% of us will have a depressive episode of some kind during our lifetime. It is likely that about half the people with clinical depression will also have another ‘mental’ problem, such as an anxiety disorder. Those suffered by children and adolescents might be in the area of behavioural or attention difficulties.
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Who gets depressed and why?

Depression has nothing to do with ‘weakness’ and there does not seem to be any particular type of person who is more prone to the disorder. However, there do seem to be ‘risk factors’ as can also be seen with anxiety disorders, that make the problem more likely. These include childhood abuse, severe trauma, having a grandparent or parent with the problem, or losing a parent while very young. The latter situation might involve losing any significant adult who lives in close proximity to the child. One Anxiety Care client traces his very early onset of depression back to the deaths of his grandparents, who lived in the family home during their declining years; and to the way his parents presented their disappearance. (They had ‘gone away’ and wouldn’t be back, with no explanation as to why.)

The situation above might have aggravated a learnt or genetic tendency towards depressive mood in this child; or the deaths, occurring during a short time period, might have built up stress levels so that a depressive response was more likely. That is, as in most cases of depression, there is no clear-cut source. When there is not even such a ‘good’ reason as this, when depression appears to come out of nowhere, this offends our need to understand things and may easily underline the belief that the sufferer is weak; thinking this way him- or herself, or thought so by the caring family. This will be particularly true if the belief that there is a reason for everything is strong within the sufferer’s family and this reason is put at the door of some minor incident involving this person, that is all they can think of. Then occurs the very good chance, as mentioned by several charity service users, that instead of accepting that they are wrong, the family assume that ‘such an over response to such a minor problem’ is a sign of weakness and lack of character. This is never useful and doesn’t lead easily to the depression being seen as a serious and, possibly, life-threatening problem.
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Symptoms

As said above, feeling generally ‘low’ and miserable is common, but when this is part of depression, it will last for months rather than days. In children and adolescents, however, this early symptom might present more as being irritable and difficult to please than miserable and can easily be missed by parents, possibly ready to view their developing child as ‘going through a phase’. Another difference is that, in adults, most activities lose their ability to draw interest and pleasure, while children and adolescents might well still involve themselves in particularly pleasurable activities and show signs of enjoying them: this too can confuse parents. Both adults and younger sufferers will probably experience tiredness and lack of energy; feel worthless or guilty on a daily basis; find it hard to concentrate and make decisions; have sleep problems (too much or too little, early waking or a feeling that getting up is too much effort); poor appetite and weight change, up or down; severe headaches; and obvious restlessness or ‘slowing down’. There might also be recurrent thoughts about death and possibly suicide.

Very young children will probably show their depression more in what they do than in what they say, and parents should be ready to listen to teachers or other adults who spend time with the child, if they suggest that there might be something wrong. For example, looking sad and being apathetic, or clowning around too much and an over willingness to take blame, possibly combined with an excess of bodily symptoms such as stomach and headache. This willingness to take note will be even more important if there is a history of depression in the family. One website (childguidance) offers a checklist of symptoms and situations that would be worth investigating if a child has suffered two or more for more than two weeks: hopelessness or sadness; change in school performance; irritability; crying spells; feelings of worthlessness, uselessness or of being stupid, ugly or guilty; aggressive behaviour.

Research seems to suggest that only some types of depression occurring at an early age lead to a greater chance of adult depression. Most young people recover within a year of developing depression, but about 10% do not. About a third of child sufferers will go on to have recurrent bouts of depression and it seems likely that the earlier the episodes start and the more often they occur, the more likely that the problem will continue into adulthood. There is a high risk of relapse with depressive illness, so no family should be tempted to embrace the thought: ‘thank goodness that’s over; let’s forget it! When the sufferers recovers; particularly if the depression has been suffered by a child or adolescent. This is always tempting, but families should question the need to stop thinking about the problem if this seems to be their ‘natural’ response.
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Suicide

Nobody wants to think that a loved one wishes to kill him- or herself and it is a common fallacy that people who talk about it never do it. A large proportion of people with depression will have thought about suicide, particularly when the illness is severe. The caring family needs to get past the idea that bringing up the subject will, somehow, make suicide more likely. It is far better to be able to discuss problems openly. And, for example, if a child or adolescent seems preoccupied with death, being ‘free’, ‘at peace’ etc.; has expressed a desire to sleep and never wake up or to be able to run away and just disappear, this should be taken seriously. And if the young person has shown an interest in the lethal capabilities of medications or chemicals round the house, or other means of ending life, it would be a very good idea indeed to bring the subject up. Other behavioural clues as described by ‘save’ could be: giving possessions away, risky behaviour and having several accidents that result in injury. It has been reported that very young children tend to believe that, if they die, they can be brought back to life again. And some adolescents who are thinking about suicide might exhibit a change in attitude towards death.

With regard to over-dosing, many people, not only children, have little or no knowledge about the amounts, of medicine they may have access to, that will cause death. So, because a person has taken a very small dose of something, or has ingested chemicals that could not possibly cause harm, this does not necessarily mean that he or she was just ‘seeking attention’: it might well have been a serious attempt that failed through ignorance. Any suicide attempt should be taken very seriously and the family’s GP, or other relevant medical advisor, must be consulted immediately.
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Treatment

Anti-depressant medication is often the first treatment of choice from overworked GP’s. These are usually one of the serotonin re-uptake inhibitors (SRI’s). These modern drugs are very useful as the general rule has always been that the ‘main’ condition should be treated when more than one problem is present in a patient. It is difficult to separate anxiety and depression, to decide which came first, and this has, in the past, lead to people being prescribed only tranquillizers, for their anxiety, when the need was anti-depressants for their depression. The SRI’s have a beneficial affect on both anxiety and depression so this problem has been reduced. However, anti-depressants may take several weeks to work and the side effects, if there are any, will be experienced before the benefit. This can be a problem, as discussed in other literature. When a person has waited until he or she cannot tolerate feeling this bad any longer, feeling marginally worse once medication has been started can be viewed as intolerable and medication may be given up. GP’s sometimes prescribe tranquillizers as well as anti-depressants if the need is urgent, which might overcome this problem.

As mentioned above, many people have little information available to them concerning the way to take medication. Several users of the Anxiety Care service have mentioned using anti-depressants as they do tranquillizers: taking one when they feel they need it. This is not the way to benefit from an SRI: the medication needs to be taken regularly for at least six months and withdrawal, when it is time, should be undertaken slowly with gradually reducing dosage and always under the supervision of the prescribing physician. With young children, medication would probably not be the first choice and even with adolescents, the dose would be small to start with and gradually built up.

With children, and probably adolescents and those displaying less severe symptoms, the physician would probably start with some form of talking treatment. A good GP might take the time to discuss the sufferer’s situation with him or her and possibly extend this to include the family. If the GP believes that the person with depression requires more specialist help, he or she will arrange a referral for psychiatric support. This will probably involve (in the UK) being seen for assessment by a hospital psychiatrist, who will then arrange treatment via a psychiatric, psychological, or community psychiatric nursing department; or possibly family therapy. Treatment offered will probably be some form of cognitive behavioural therapy (CBT), which will work on the patient’s negative thinking and beliefs. Psychologists and psychiatric nurses cannot prescribe medication, so a sufferer who is deemed to require this as well as talking help, will continue to see his or her GP or a psychiatrist; and visits to a supervising psychiatrist might be part of talking help provided by other agencies even if medication is not involved.
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Mixed anxiety/depression

This is not a distinct disorder but is a description used when a person has symptoms of both anxiety and depression that don’t meet the criteria for designation as a full disorder or either type. Reputedly, mixed anxiety/depression is the most common problem seen by GP’s. Typically, a sufferer will experience a low and/or sad mood with lack of interest and pleasure in things and will experience a good deal of anxiety or worry. According to the World Health Organisation, the following symptoms are frequently present: disturbed sleep, fatigue or loss of energy, poor concentration, disturbed appetite, dry mouth, tension and restlessness, tremor, palpitations, dizziness, suicidal thoughts or acts, loss of libido (sexual interest). Other sources suggest that feelings of worthlessness, hopelessness and low self-esteem will also be involved. Where suicidal thoughts are present, this will require professional support, and sufferers in this category will usually be treated with anti-depressant medication or talking help as discussed above.
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