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Depression

Overview
Causes
Symptoms
Risk Factors
Prevention

When To Seek Help
Treatment Options
References
Where To Seek Treatment

Singapore General Hospital
Contributed by Dept of Psychiatry

Overview

Depressed mood is a universal experience in response to disappointments, discouragements and defeats. When a person fails his exam or when a close friend emigrates to another country, it is normal to feel sad. But this feeling of sadness does not last more than a few days, and usually does not interfere with one’s daily activities. It is just a depressed mood and not an illness.

In contrast, depressive illness lasts for weeks to months, even years. It improves with treatment but is prone to recurrence. These symptoms are severe enough to cause loss of efficiency and disruption to work, family life and studies.

Annual prevalence rates range from 0.80-5.8% whereas lifetime prevalence rates range from 1.5-16.4%. In Singapore it is about 5% (Chua et al, 2004).

Women have a relatively higher rate of occurrence of depression than men. The sex ratio is 2:1.

In females, depression is more common in the married than the never-married groups. Women with three or more children below age 14 are more at risk. In males, the single, divorced and widowed are more likely to be depressed.

Depression is much more common in those in the lower income group. The retired or unemployed are more likely to be diagnosed with depression. Those living alone are also at a higher risk. Social isolation generates feelings of loneliness such that in times of trouble there is no one to confide in.


Causes

There is no single cause for depression. Many factors play a role including genetics, chemical imbalance, stress, physical illness and negative thinking patterns which affect a person’s reaction to events.

Depression runs in families, and the more closely related one is to the depression sufferer,
the higher the chances of developing depression.

Some of the symptoms of depression may be caused by abnormal secretion of hormones such as thyroid and parathyroid hormones, or a disruption in the delicate balance in the hypothalamus, pituitary and adrenal glands.

It has been postulated that in depression, there is insufficient transmission of nerve impulses involving certain neurotransmitters such as noradrenaline, serotonin and possibly dopamine.
Research has firmly established that life events are associated with the onset of depression. Events such as loss of a loved one, business failure and broken relationships are common examples. Depressed patients report an increase of life events in the last six months before the onset of depressive symptoms.

Certain personality traits predispose a person to depressive illnesses. Obsessive compulsive traits are characterized by perfectionism, in particular, setting impossibly high standards which results in repeated disappointments when the standards are not met. Dependent personalities have a great need to be taken care of and depend on others to make decisions or to do things for them. Borderline personalities are characterized by unstable interpersonal relationships, poor self-image, and overwhelming fears of abandonment.

Substance abuse can cause chemical changes in the brain that affect mood (alcohol and some drugs are known to have depressogenic effects). The negative social and personal consequence of substance abuse can also lead to family disruption and discord.

Medical conditions associated with depression include:

  • Cancer
  • Infections
  • Prescription drugs such as steroids, medication for cancer, cholesterol, heart conditions, hypertension
  • Neurological disease such as brain tumours, dementia, Parkinson’s disease, traumatic brain injury, HIV-associated brain pathology
  • Vitamin deficiencies such as folate, vitamin B12
  • End-stage renal disease
  • Systemic lupus erythematosus

Symptoms

A person may be diagnosed as having an episode of major depression if he experiences five or more of the following symptoms for two weeks or longer.

  • Depressed mood or sadness most of the time
  • Lack of energy, feeling tired all the time
  • Inability to enjoy things that used to bring pleasure
  • Withdrawal from friends and family
  • Irritability, anger or anxiety
  • Inability to concentrate
  • Significant weight loss or gain
  • Significant change in sleep patterns
  • Feelings of guilt or worthlessness
  • Physical symptoms, e.g. aches and pains even though nothing is physically wrong
  • Pessimism and indifference
  • Thoughts of death or suicide

Persons with depression may, in some cases, entertain delusions (false unshakeable beliefs) usually involving any of the three themes, namely, guilt, ill health or poverty. These beliefs cannot be reasoned away and are not shared by others in the family or social circle.

Persons who are depressed sometimes report hearing voices scolding them, telling them they are useless and that they should go and die. Worse still, the voices may also tell them to commit suicide.


Risk Factors

In females, depression is more common in the married than the never-married groups. In males, the single, divorced and widowed are more likely to be depressed.

Women have a relatively higher rate of occurrence of depression than man.

Depression is more common in those in the lower income group. The retired, unemployed or part-time employed are more likely to be diagnosed with depression. Those living alone are also at a higher risk.

People who become clinically depressed have generally experienced more severe difficulties in childhood than those who do not become depressed.


Prevention

How you can help yourself

Express your Feelings
Keeping a tight lid on one’s feelings will, in the long run, intensify the feelings and drive one to deeper levels of depression. If you have a friend or a confidant, speak to him candidly about how you feel.

Time Management
Think about activities that brought pleasure and which are no longer done after depression set in. starting with small steps, begin to get back into doing them. Set realistic goals. In light of your depression, you may not be able to achieve what you were previously capable of, but doing something simple is better than not attempting at all.

Social Interaction
If you have withdrawn from your friends, make some effort to meet up again. Even thought the natural inclination is to keep to oneself, it is advisable to be in regular contact with friends or family. There is no need to talk about one’s problems; just being around with people helps rid one of feelings of isolation and loneliness.

Keep a Diary/Write Letters
This is a way of expressing your feelings. You may not always have friends or family with you, and keeping a diary or writing to yourself can take their place for the time being. You can even write notes to yourself, encouraging yourself as if you were talking to a beloved friend.

Guard your Self-talk

Refrain from confessing negative words like ‘I am useless’ or ‘it can never change’. Let your self-talk be positive, optimistic and hopeful. It may take effort to keep your language upbeat when you feel down, but making an effort to do so will help change your thinking pattern.

Physical Exercise
When depression is moderate to severe, the sufferer has neither energy nor drive to get up and exercise. With the lifting of depressed mood, the patient can be encouraged to do some regular exercise. Exercise releases endorphins, which are in themselves capable of elevating mood.

Support Groups for Patients
A support group can be invaluable in supporting persons recovering from depression. Groups comprising persons suffering from depression can provide support and encouragement.

Actions to avoid

Alcohol
Depression sometimes drives people to drink and sometimes alcohol abuse leads to depression. Drowning your sorrows will not help you overcome depression in the long run.

Making Major Decisions
There are many decisions a depressed person may need to make. Some are major decisions which require the person to be rational, calm and objective. Hence, it is always wise to postpone making these decisions until the depression has lifted.

Suicidal Actions
Depressive disorders make one feel exhausted, worthless, helpless and hopeless and may make some people feel like giving up. These negative views are part of the depression and typically do not accurately reflect the actual circumstances. Therefore do not give in to the urge to end your life.


When To Seek Help

You should seek help for depression when it negatively affects one or more aspects of your life, such as your friendships, family, job or general outlook on life. If you are unsure, there is no harm in getting an assessment just to reassure yourself. Many persons may be reluctant to seek treatment for various reasons, whether they are afraid of being given a psychiatric diagnosis, and of the stigma attached to a mental illness. Some people have the notion that they will be sent to the psychiatric hospital and confined there.

Most depressed people do not require hospitalization and only need outpatient treatment. If left untreated, depressive symptoms may last for months to years and is more difficult to treat if it is more and more severe.


Treatment Options

Drug Treatment
Antidepressant medications work by increasing the transmission along serotonin and noradrenaline nerve fibres in the brain. Medications are chosen based on the type of depression and the side effect profile.

Once a drug has started to work, the patient is expected to improve with continued intake of antidepressant medication. By about two months, most symptoms would have disappeared. The medications should be continued for 9-12 months after remission of symptoms. Premature discontinuation of treatment even in the absence of symptoms may lead to relapses several months later.

Electroconvulsive Therapy (ECT)
ECT is the most effective treatment for depression where rapid reduction of symptoms is required. Thus it could be life-saving for those who are suicidal, with depressive stupor or who cannot tolerate the side effects of medication.

Psychological Treatments
Psychological treatments require the patient to talk about their problems, also referred to as ‘ventilation’. Psychological approaches work best for persons who are able and willing to describe their thoughts and feelings. Types of therapy that may be used for depression include Interpersonal Psychotherapy, Cognitive Behavioural Therapy or Psychodynamic Psychotherapy. What sort of therapy will be administered depends on the skills and expertise available.


References

The above are excerpts from the book titled ‘Depression: The Misunderstood Illness’ written by Associate Prof Leslie Lim, Senior Consultant, Dept of Psychiatry, Singapore General Hospital which is available at major bookstores.


Where to Seek Treatment

The medical institutions within SingHealth that offer consultation and treatment for this condition include:

Singapore General Hospital
Dept of Psychiatry
Outram Road, Singapore 169608

Online : Request Form
Email : appointments@sgh.com.sg
Call : +65 6321 4377

Overseas Referrals:
Online: Request Form Email: ims@singhealth.com.sg Call +65 6326 5656


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