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% 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.
Feeling down?
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."
Other conditions and depression
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% 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.
Youth suicide
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% 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."
Post-natal depression
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% 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.
The elderly
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."
Treatment
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."
Medication
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% 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."
Want some advice?
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
