Recognising when someone is depressed rather than just sad

Depression is a common, disabling condition. It is also a confusing condition, occasionally difficult to distinguish from day-to-day unhappiness. The key to managing depression in adults lies in recognising when someone is depressed rather than just sad, and offering them support and help as soon as feasible. It is important to remember that unhappiness is not the same as depression, and there is no benefit in ‘medicalising’ unhappiness.

The WHO estimates that, by 2020, depression will be the second most common cause of disability worldwide, after heart disease. Over the course of a life-time, the chance of developing depression at some point is between 10% and 17%. Depression is twice as common in women as in men.

Depression can vary greatly between individuals. The symptoms and signs depend on the person’s general character, their life situation, any stresses triggering their depression, and various other factors. 

Common symptoms include: low mood or feeling down; loss of interest and enjoyment in activities that are usually pleasurable; reduced energy and activity; marked tiredness after slight effort; reduced concentration and attention; diminished self-confidence and self-esteem; ideas of unworthiness and guilt; pessimistic or bleak views, hopelessness and helplessness, ideation or acts of self-harm, disturbed sleep, especially difficulty falling asleep, fragmented sleep, early morning waking or, unusually, excessive sleep; and reduced or, unusually, increased appetite.

In any individual, some causes for depression may be readily apparent: a series of stressful events, for example, or serious medical illness. For many people, however, depression just seems to appear out of nowhere, and the individual might never identify a specific cause or triggering factor. While depression tends to run in families, most people with depression in their family will not develop the condition.

People with depression commonly require assistance and support in order to deal with their symptoms, enter recovery, and maintain wellness. It is important that the individual can talk openly about their symptoms without fear of criticism or judgment. It is also important that any issues relating to alcohol or other drug use are resolved. 

For depression itself, there are psychological treatments (such as cognitive behaviour therapy or CBT), ‘biological’ treatments (such as medication) and social interventions, all of which can be combined to suit the needs and circumstances of any given individual.

Psychological treatments 

The most commonly-used psychological treatment is CBT, which focuses on the use of cognitive strategies (ie. thinking patterns and habits) and behavioural strategies (ie. actions), in an effort to re-frame depressive thoughts, enhance coping strategies, reduce symptoms and promote recovery. Usually, the therapist will meet the patient once per week and point out unhelpful thinking or behaviour patterns that deepen or prolong depression. Together, the patient and therapist identify ways to address these errors and habits, and incrementally improve symptoms. 

Other forms of psychotherapy include inter-personal therapy and mindfulness, involving careful, non-judgmental awareness of thoughts, emotions and actions. Social interventions include provision of social support, increasing social engagement (ie. going out) and befriending services for individuals who are isolated and poorly-integrated.

Pharmacological treatments

As regards medication, most guidelines now recommend newer medications (selective-serotonin re-uptake inhibitors) as first-line treatments for depression. St John’s wort, a herb, is another useful treatment, although users should note that it significantly reduces the effectiveness of the contraceptive pill, possibly resulting in pregnancy. 

Choice of medication will depend on the severity of the depression, the patient’s treatment history and patient preference. It is important that the decision to start an antidepressant medication is made jointly between the patient and the doctor or mental health team, and is carefully reviewed after around six weeks, to see if progress is occurring. If progress is not satisfactory, treatment needs to be adjusted or re-considered.

All medications have various effects on the brain. That is not to suggest that the cause of depression in any given individual can be simply ascribed to any specific ‘chemical imbalance’ in the brain. The biology of the brain is as-yet poorly understood, so any simple biological explanations for depression over-state how much is really understood about the brain. What is clear, however, is that antidepressant medications have some effects and that a majority of individuals with depression find these effects helpful.

Approximately two-thirds of patients with moderate or severe depression respond to the first antidepressant prescribed. In these patients, the medication should be continued for six to nine months after recovery. For individuals who have several episodes, there is evidence to support treatment for up to two years. If there is no or insufficient response to the first antidepressant after several weeks, it is recommended to increase dose, switch to a different antidepressant, or engage in a broader re-consideration of therapeutic options. In the event of poor response after a second antidepressant, alternative treatment strategies may be required (eg. an anti-psychotic medication or lithium, a mood-stabilising medication or, in certain cases, electro-convulsive therapy).

Many individuals experience no side-effects whatsoever from antidepressants. Others experience mild adverse effects (eg. transient nausea or sickness in the stomach) but opt to stay on the medication on the basis that the positive effects (improved mood) exceed any side-effects. Other side-effects may include headache, drowsiness, weight change and various others depending on the specific medication. In all cases, potential side effects should be discussed carefully prior to treatment.

Some 80% of people with depression recover fully, while 20% experience ongoing problems. In severe depression, the lifetime risk of suicide is 10-15% but it is much lower in less severe depression. Prognosis is better if the person does not use alcohol or drugs, adheres to their personal treatment plan, and takes active steps to maintain mental wellness following recovery; ie. has a healthy diet and lifestyle, maintains good physical health, and sustains links with family and friends.

Case history: Maura

Maura, a 48-year old woman, attended her GP complaining of problems sleeping. When asked about her mood, Maura said her mood was fine. She said she had always been ‘a worrier’ but never had trouble sleeping before. When her GP probed a little further, Maura revealed that she had difficulty falling asleep for the past three months, and also woke much earlier than usual. She had lost some weight and was no longer interested in her weekly bridge evening. Maura insisted she was not depressed but admitted she was more anxious than usual ‘for no reason’. ‘I’m just being silly’, she said.

Maura’s GP explained that Maura fulfilled some of the criteria for mild depression, and would likely benefit from some form of supportive psychological therapy. The GP took a blood test to check Maura’s thyroid function (to outrule an under-active thyroid gland) and asked Maura about her periods (in order to outrule menopause as a contributory factor in Maura’s psychological complaints). These being outruled, Maura attended a psychotherapist once a week for eight weeks in order to discuss her concerns, various stressors in her life and take practical steps to promote a mentally-healthy lifestyle. She recovered fully.

Case history: Paul

Paul, an 18-year-old boy, had been doing well in school until, abruptly, he stopped attending. He pretended to leave home in the morning but spent the day alone, sitting in the park. After two weeks of non-attendance, his parents received a phone call from the school. They confronted Paul at home. Paul readily admitted he hadn’t been attending school. He said ‘there’s no point’ and ‘I might as well be dead.’ Paul’s parents found a suicide note in Paul’s room and a rope stored under his bed.

Paul’s parents brought Paul to see their GP who immediately referred Paul to a psychiatrist. It turned out that Paul had been experiencing low mood, suicidal thoughts, and extreme hopelessness for the previous four months. This had started with no apparent trigger, apart from the usual ups and downs of teenage life. Paul required careful monitoring, treatment with antidepressant medication, and regular sessions with a psychological therapist, focusing on coping skills. After about one month, Paul felt substantially better, and after nine months the anti-depressant medication was discontinued. Paul continued to attend the coping skills therapy for over one year, and had no recurrence of his depression.

Further information

For anyone who is feeling suicidal, the Samaritans (www.samaritans.org) provide a listening service to anyone who contacts them (Tel 116 123; email jo@samaritans.org). Pieta House (www.pieta.ie) also offers support, both for those who are feeling suicidal and those who are bereaved by suicide (Tel: 1800 247 247; or text HELP to 51444, and standard message rates apply). 

Aware is an Irish organisation which provides extensive and reliable information on its website (www.aware.ie). The mission of Aware is to help build a society in which individuals with stress, depression, bipolar disorder and other mood disorders, and their families, are supported and understood, do not experience stigma and can avail of a wide variety of appropriate therapies. Its website is informative, practical and reliable.