Depression

The extent of the problem
Depression is among the most common psychiatric problems. Around 60 - 70% of adults will at some time experience symptoms of depression of enough intensity to affect their life. Up to 50% of General Practice attenders may have some depressive symptoms and about 5% will present with major depression. At least one patient with depression is likely to present at each surgery session. It has recently been estimated that the total cost of depression to the NHS is £333 million. Indirect cost due to lost social and economic productivity may be three times higher than the direct cost quoted above. Moreover, depression can be life threatening. Of the 4,000 people who commit suicide every year most have been depressed.

What is depression?
Depression may present in various forms, and symptoms like those listed below occur in varying proportions from one individual to another. In some, it begins as a clear reaction to a major event. In others, no such event is identifiable. For some people the depression occurs as a clear episode, for others it can be quite chronic and for others it can alternate with ‘high’ episodes.

Mood changes are primary, shown as feelings of persistent sadness, of being down in the dumps, of hopelessness and helplessness. Anxiety and increased irritability are often present.

Cognitive changes of various degrees of intensity are experienced, such as a lack of concentration, confused thinking, indecision and difficulties with remembering. Typically, the content of thought is very negative and pessimistic, people seeing themselves as inadequate or even as bad, finding their environment unfulfilling and their future bleak.

Biological changes affect sleep, appetite, weight, sex-drive and the ability to enjoy usual activities. Patients often complain of aches and pains, or excessive fatigue and of slowness of thinking and movement.

Behavioural and motivational symptoms are characterised by inactivity, unwillingness to initiate activities, avoidance of work and social activities, crying and sighing.

Causes
No single cause of depression has been identified and the consensus of opinion is that several factors can act together, for example, genetic vulnerability, family history, social vulnerability (loss of social support, isolation, socio-economic disadvantages) and psychological vulnerability involving a history of loss and disruptive childhood experiences. Often episodes of depression appear to be precipitated by major life events, such as the death of a loved one, divorce, financial difficulties or loss of a job.

The common pathway of these several interacting factors can be both biochemical and psychological. In some depressions, there is an imbalance in several brain chemicals. Psychological changes are more universal, the main features being a striking negative bias in the interpretation of events and in memory, and predominance of dysfunctional or unhelpful attitudes regarding oneself and the world.

Treatments
During the past few years very effective treatments have been developed for depression. These include anti-depressant medication and short-term psychological treatments. Both these approaches can provide relief from depression within 3 to 4 weeks and long lasting relief within 3 to 6 months.

Psychological Therapies
Cognitive or cognitive-behavioural therapy has been the most extensively evaluated. It has been shown to be at least as effective as anti-depressant medication, but to be superior to medication in the prevention of relapse and recurrence of illness.

Cognitive Therapy is structured and collaborative; patient and therapist work together on explicitly agreed goals. Different components of therapy focus on behaviour or on thoughts as means of alleviating low mood. Time may be spent on reestablishing previous activity levels. The sufferer learns to combat the negative style of thinking which maintains depression and to develop coping skills which help not only in acute episodes of depression, but also to face future difficulties and major events.

Medication
For the most severe depressions, anti-depressant medication with or without psychological treatment should be employed. Different types of medication are now available and the GP’s choice of anti-depressant will depend on individuals patient’s character.

The combination of psychological treatment not only enhances compliance with medication but also increases the likelihood of long lasting treatment effects.

What are Behavioural and Cognitive Psychotherapies?

Behaviour Therapy, Cognitive Therapy and Cognitive Behaviour Therapy have some common features. They are based firmly on research findings and derive from specific theories. The focus is mainly on the here-and-now, rather than the past, and the main goal of therapy is to help bring about changes in the person’s life which are measured and evaluated. Goals for change may involve:

• A way of acting eg. being more outgoing
• A way of feeling eg. being less scared or less depressed
• A way a thinking eg. learning to problem solve or get rid of self defeating thoughts
• A way of dealing with physical or medical problems eg. lessening the difficulties associated with back pain.
• A way of coping eg. training developmentally disabled people to care for themselves

Cognitive or Behaviour Therapists may work with individuals, groups or families, and therapy is time limited. The approaches can be used to help any person – irrespective of intelligence, insight or other abilities.