Estimates suggest that one in three of us will develop depression at some time during our lives.

Australia's first national survey of mental health published by the Australian Bureau of Statistics (ABS) in 1998, reported that one in five Australian adults suffered from anxiety, substance abuse problems or a serious mood disorder within the previous twelve months. While statistics vary, estimates suggest that one in three of us will develop depression at some time during our lives.

Tellingly, however, the ABS survey found that only 38 per cent of those suffering from symptoms relating to mental disorders sought any form of professional help to deal with their problems. Speaking at an international congress on depressive disorders in Melbourne in 1999, South Australian psychiatrist Professor Robert Goldney said community denial of depression was so prevalent and powerful that the health system may be fighting a losing battle.

Most of us casually use the word "depressed" when we're feeling a little down. Feeling sad, however, is a perfectly normal and generally short-lived human experience. Clinical depression is another thing altogether.

"I think it's very important to emphasise that when we (health professionals) use the term depression we mean something quite different from day to day experience," says Professor Scott Henderson, clinical adviser to the Federal Department of Health.

"Clinical depression is an abnormal state that persists for weeks or months. It is not under conscious or volitional control, although others may say 'why don't you snap out of it', which is the very last thing these people can do."

"There isn't a blood test for depression but it can be diagnosed quite accurately," says Professor Beverley Raphael, Director of Mental Health Services in NSW. "If you've been feeling miserable for more than two weeks in the profound sense, are unable to function in the usual way, have lost interest in the outside world or have any thoughts of suicide then it's time to go to your doctor."

Generally, symptoms of depression can include:

• a depressed mood for longer than two weeks;
• a loss of interest or pleasure in most activities;
• significant change in weight or appetite;
• being unable to sleep or needing excessive sleep;
• agitation or lethargy;
• loss of sexual drive;
• fatigue or loss of energy;
• lack of concentration;
• feelings of worthlessness or guilt;
• recurrent thoughts of death or suicide.

Depressive disorders can be classified either as unipolar, involving depression only, or bipolar, where the person swings from periods of deep depression to episodes of mania characterised by an extreme elevation of mood, over-activity, reduced need for sleep and loss of inhibitions. The person may feel well, even on a "high", but the existence of such behaviour should always be clarified so a diagnosis of bipolar disorder is not overlooked. The main types of unipolar depression include major depressive disorder, which generally involves five or more of the symptoms listed above occurring for at least two weeks, and dysthymia, a lower-grade but chronic condition persisting over a lengthy period of one to two years.

In the past, mental health professionals have also referred to endogenous and exogenous depression. What was called endogenous depression has no obvious external cause, seemingly coming "out of the blue", while exogenous depression is described as reactive, being triggered by traumatic life events.

While endogenous depression may previously have been attributed to genetic inheritance and biochemical imbalance, current thinking suggests that people who suffer from reactive depression also possess an inherent susceptibility to the development of the illness. "There used to be a view that anyone could get reactive depression," says Professor Raphael. "While that's still true, the biologically vulnerable are much more at risk."

A number of conditions, both physical and mental, often occur together with depression. The most common of these is anxiety, which, according to the ABS survey, occurs in 80 per cent of people with depression. A vulnerability to substance abuse is also common.

"The anxiety symptoms which frequently occur with depression include agoraphobia (a fear or dread of open spaces and/or of going out in public), panic attacks and generalised anxiety," says Professor Henderson. "So the person with depression often has palpitations, headaches, shortness of breath and a continual sensation of 'butterflies' in the stomach." Depression may also contribute to or result from physical conditions and disabilities. People suffering serious injuries or conditions such as cardiovascular disease, diabetes and cancer often demonstrate depressive symptoms. Not surprisingly, untreated depression is likely to adversely affect treatment outcomes in many of these cases.

Rachel was only 16 when she descended into a severely disabling depression. "I was all alone, suicidal and mad at the world," she recalls. "The four months before I was diagnosed with depression were the worst four months of my life, and I felt the only way out was death."

While people of all ages and circumstances can suffer from depression, certain life stages have a higher incidence of the disorder than others.

Perhaps most disturbing of all is the escalating incidence of mental health problems amongst the young. Youth suicide has emerged as a major social issue in Australia, recently challenging road accidents as the leading cause of death amongst males in the 15-24 age group.

According to the Archives of General Psychiatry in the United States, rates of clinical depression have increased in each succeeding generation born since 1915, and the growing numbers of people suffering from the illness are primarily emerging amongst the young. Australia's current rate of youth suicide is now three times that of the 1960s.

The question of why such trends are emerging is a complex one. "Some theories suggest that kids are experiencing more stress due to the complexity and pressures of their lifestyles," says Professor Raphael. "There are fewer rewarding achievements and more insecurity in young lives with more competition to achieve anything at all. Others speculate that biological predispositions are becoming greater, but very little is really known."

Jack Heath, whose young cousin committed suicide in 1992, has set up a youth suicide prevention service on the Internet called Reach Out! at www.reachout.asn.au. "In many ways it's really quite uncharted territory," he says. "In any suicide there will be a complex cocktail of contributing factors. If you speak to clinicians they'll say suicide is virtually impossible to predict."

While that might sometimes be the case, Andrew Kay of suicide prevention group, Here for Life, suggests that 90 per cent of suicide victims give warning signs. "A good starting point is to ensure the wider community, and particularly those working with young people like teachers, parents and youth workers understand the warning signs and broad concepts of suicide prevention," he says.

Warning signs may include:

• statements alluding to suicide - these should be taken seriously;
• previous suicide attempts;
• extended periods of depression (crying, sleeplessness, loss of appetite, hopelessness);
• sudden changes in behaviour (withdrawal, moodiness, apathy);
• artistic expressions of suicide, for example, drawing or sketching of morbid or death-like scenes involving a character like the artist;
• the giving away of possessions.

Jack Heath believes it is important to take notice of warning signs, but he also cautions against becoming too obsessive. "Suicide prevention is ultimately about generating hope and meaning," he says. "It's important that when we talk about the serious issues that are out there, we let people know that there are resources available to help them."

A report issued by the National Health and Medical Research Council in 1998 highlighted the need for health and social services to pay more attention to depression in women during pregnancy and after childbirth. "Depression after childbirth is poorly recognised by health care professionals who are often seen by women to be more concerned about the welfare of the baby," the report said.

Ten to 15 per cent of women suffer a major depressive episode, which may become evident months or even a year after the birth. While post-natal depression has often been overlooked in the past, the condition is now receiving some overdue attention with support programs emerging around the country.

Pregnancy and parenthood are often stressful for a mother and her partner. Difficulties in coping with the day-to-day trials of parenthood are often perceived as being "normal". Overlooking an underlying problem of depression may result in the mother feeling inadequate, it can disrupt the bonding process, and place undue stress on the relationship with a partner.

Support programs can be of enormous help. Hospital antenatal services, community support groups and interested psychiatrists are developing programs. Ask your doctor or hospital about the help available in your local area.

While the prevalence of depression generally decreases with age, elderly people are still at risk of depression. "One under-recognised group our research suggests is at high risk of depression is elderly people in nursing homes," says Professor Henderson. "This is not an indication that nursing homes are nasty places, but that many of these elderly people are also physically or mentally unwell."

Depression, in the majority of cases, is eminently treatable. The first step is recognition of the problem. This could certainly be improved by overcoming the community's denial and the widespread attitude that all you have to do is pick yourself up and get over it. A general practitioner will often be the first port of call, and seeing a professional can be a great relief in itself. "There's been an extensive education campaign with GPs across the country so they're pretty good at recognising a problem and responding appropriately," says Professor Raphael.

According to Professor Henderson, this is often a good time to involve family members. "The GP could perhaps suggest that the depressed person bring someone along to the next appointment," he says. "It is necessary to explain the condition to the patient's family as you would for asthma or diabetes and initiate support and understanding." Part of every treatment will involve some sort of psychotherapy. "The most common and effective form of psychotherapy is cognitive-behavioural therapy, which addresses the negative thinking styles which become a very fixed pattern in depression," says Professor Raphael. "It focuses on helping the person to understand their thinking styles and reframe them more positively. Some preventative programs called optimistic thinking really try to build on the optimistic component of thinking styles."

Many people will respond to cognitive-behavioural therapy alone, but in other cases anti-depressant medication may be required. Clinical depression can usually be helped through simple pharmaceutical treatment. "Treatment does not, as many people think, mean medication, but we are dismayed to find from research that the general public of Australia think that anti-depressants are addictive," says Professor Henderson. In a recent South Australian survey, 40 per cent of the public viewed anti-depressants as harmful. On the contrary, drugs available today are very effective, non-addictive and have fewer side effects than ever before, being harmless even in overdose.

"The medication really was totally positive in its impact," says Vince Bruce of his own experience (see 'Judging Depression' on page seven). "While I basically recovered in six weeks or so, some evidence says that if you go off the medication in less than 18 months there is a higher possibility of a relapse. I was religious in taking the medication for the first 15 months and basically weaned myself off it in the last three months. I had no problem at all about stopping it."

It is a message that Professor Raphael further emphasises. "If your doctor puts you on treatment, be it psychotherapy or anti-depressants, it's very important to stick to the treatment regimen."

The world's first Internet-based suicide prevention service, Reach Out! offers anonymity to those who might otherwise be reluctant to seek help and capitalises on the fact that at least half of all young people are regular 'net users. Whether anonymity is an issue or not, Reach Out! is a good place to start a search for much needed information, assistance or referrals for all those concerned with youth suicide. Its "whole-of-community" approach provides three distinct "sub-sites" for three target groups: Young people (Chill Out!), their families and friends (Family and Friends) and the professionals who deal with them (Professional Forum). Visit Reach Out! at: www.reachout.asn.au

Former Supreme Court Justice Vince Bruce's battle with depression became a very public one during 1998.

A history of severe migraines and a serious car accident in 1988 left him with a debilitating depression, yet he was unaware of his condition. "I found it difficult to function, spending long but unproductive hours at work just going round in circles," he recalls. "I had poor sleeping habits, waking up very early in the mornings, and was tense and irritable, but I put it down to other sources and told myself I just had to battle on." When he finally attended a psychiatrist looking for answers in December 1997, he was shocked with the diagnosis of severe clinical depression. "I think it would be fair to say that my view of depressed people had always been 'what's wrong with you! Just pick yourself up and go on and do it'."

It was an attitude reflected by one particular Sydney newspaper, which campaigned against Bruce when details of his condition and its effect on his work became public. He was also asked to show cause to the NSW Parliament as to why he should not be dismissed.

Support was, however, forthcoming from many others. "If you sit down in a movie theatre, you can probably touch someone from where you're sitting who either has depression, has had it or will have it. It's a very common illness and I encountered a great deal of support and understanding."

Once diagnosed, the road to recovery was swift. "It was just before Christmas so I had six weeks off, barely read a newspaper, had a lot of sleep, saw the psychiatrist a number of times and was placed on anti-depressant medication," he says. "By February I was better. It was a matter of addressing the problem, and having got over the depression I then addressed the physical problems that had precipitated it." While he was required to continue his course of medication for 18 months to guard against relapse, the condition that had hung over Vince Bruce for 10 years was essentially able to be remedied in a matter of six weeks.

Although he eventually won his battle with the judicial commission, Bruce left the Supreme Court of his own accord in March this year to pursue other interests including the setting up of an online depression information resource on the Internet which will be launched in February 2000 at www.depressionaustralia.com.au

A number of people have written very effectively about their own experiences of depression. NSW Premier Bob Carr was sceptical about depression, suggesting that "life is inherently disappointing for some people", until he read William Styron's book, Darkness Visible. "Styron said depression was an experience unimaginable to those who have not suffered it," Carr says. "The book is so moving your instinct is to gallop through it to get to the end as you are so uncomfortable reading it."

Another book that gives a powerful insight into depression is A Malignant Sadness by Lewis Wolpert, a professor of psychiatry who himself suffered from depression. The National Health and Medical Research Council has published a number of informative booklets in recent years to assist sufferers and their families. For details on how to obtain copies phone 1800 020 103.

The Australian Rotary Health Research Fund (ARHRF) has launched a Mental Illness campaign to raise funds and provide grants for research into mental illness, and to promote a greater understanding and tolerance through education to reduce the stigma surrounding mental inllness. For further information regarding the ARHRH Mental Illness campaign, visit www.rotarnet.com.au or phone (02) 9633 4888.

The Internet is a great source of information on depression. A good place to start is www.depression.com

• Lifeline: 131 114 (24hrs, 7 days) (02) 9951 5522
• Kids Helpline: 1800 551 800 (24hrs, 7days)
• Youthline: Parramatta (02) 9633 3666