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What is Depression?
People often ask "What is the difference between the illness that is 'depression' and the healthy experience of feeling depressed?" Unfortunately there is no simple, easy answer to this question.
One way to explain it is…
Feeling depressed is a healthy reaction to an external life event or situation, whereas 'depression' is when these feelings are out of proportion to external life events and/or continue longer than a healthy recovery period. Usually the 'depressed' feelings are far stronger with depression than we experience when 'depression' isn't present.
We all know the feeling of being down. Here we provide an insight into what it is like to have depression by sharing the descriptions from people with different experiences of depression in the hope that it will help others to better understand what it is to live with depression.
If you are depressed, I'll bet that you can tell me what the symptoms are but I'll also bet just as much or more that you don't know what depression actually is.
REACTIVE VS ENDOGENOUS DEPRESSION
Reactive vs Endogenous Depression - The theory that depression is either 'reactive' or 'endogenous' in origin is losing support. It is now more commonly believed that both environment and genetic history play a part.
'Endogenous' is the term given to depression that has no obvious cause – that is, was not brought on by a specific life event or circumstance, but rather appears to come from nowhere.
Both are related to chemical changes in the brain, however differ in terms of 'which came first – ie did the depression come first, making life's problems seem far greater than they are, or did life's problems bring on the depression?
'Reactive' depression is the term used for depression thought to be caused by a specific event or circumstance, such as relationship problems or loss of someone you love either through death or the end of a relationship, losing or changing jobs, or anything else that you find traumatic. This doesn't refer to grief, which is normal and healthy and temporary, but to depression which lasts well past the time that you would expect to start recovering from grief, and is very unhealthy.
Psychological Reason(s) for depression:
Did you know that depression is anger turned inward towards yourself? If you are depressed l'll bet that you "beat yourself up" mentally, continually giving yourself negative self-talk. Also, my guess would be that there may be some perfectionism and/or people pleasing involved, along with anxiety of some sort.
If you are in therapy for depression and finding ways to RELEASE these continual negatives thoughts, then you are getting good therapy. If you are not finding ways to release these negative thoughts permanently, then you should probably move on to get therapy from someone who knows how to help you do just that.
The Medical Model focuses more on the genetics and the physical effects and symptoms of depression.
Depression, in the medical model sense, is a medical illness (as opposed to the result of psychological issues) that causes a persistent feeling of sadness and loss of interest (symptoms). Depression can cause physical symptoms, too.
There are many kinds of depression, ranging from lesser more acute forms of depression to what is called major depression, major depressive disorder and clinical depression (which is any depression that requires clinical intervention). It affects how you feel, think and behave (instead of how you think, feel and behave causing the Depression).
Depression can lead to a variety of emotional and physical problems (symptoms that obviously can get worse if the Depression goes unchecked). You may have trouble doing normal day-to-day activities, and depression may make you feel as if life isn't worth living. More than just a bout of the blues, depression isn't a weakness, nor is it something that you can simply "snap out" of.
The medical model goes on to say that "Depression is a chronic illness that usually requires long-term treatment, like diabetes or high blood pressure. But don't get discouraged. Most people with depression feel better with medication, psychological counseling or other treatment."
So, the medical model says pretty much, "Don't worry, you're going to have the "illness" pretty much for the rest of your life, but you can "manage" it with "medication, psychological counseling, or other treatment".
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Symptoms of Depression
· Feelings of sadness or unhappiness
· Irritability or frustration, even over small matters
· Loss of interest or pleasure in normal activities
· Reduced sex drive
· Insomnia or excessive sleeping
· Changes in appetite — depression often causes decreased appetite and weight loss, but in some people it causes increased cravings for food and weight gain
· Agitation or restlessness — for example, pacing, hand-wringing or inability to sit still
· Irritability or angry outbursts
· Slowed thinking, speaking or body movements
· Indecisiveness, distractibility and decreased concentration
· Fatigue, tiredness and loss of energy — even small tasks may seem to require a lot of effort
· Feelings of worthlessness or guilt, fixating on past failures or blaming self when things aren't going right
· Trouble thinking, concentrating, making decisions and remembering things
· Frequent thoughts of death, dying or suicide
· Crying spells for no apparent reason
· Unexplained physical problems, such as back pain or headaches
Also, feelings of sadness, lethargy, helplessness, hopelessness, worthlessness, difficulties with decisions, memory, concentration, loss of interest, energy, changes to sleep patterns – difficulty sleeping or staying awake, changes in weight – either significant loss or gain in weight, relationship problems with partners, friends, family, colleagues, isolation, thoughts of death, suicide,
Source: World Health Organisation's International Classification of Disease
Two weeks of abnormal depressed mood
Loss of interest and decreased energy
Loss of confidence
Recurrent thoughts of death
Agitation or retardation
Change in appetite
Mild depression includes the first two symptoms and at least one other. Severe depression is the first two symptoms and at least five others.
For some people, depression symptoms are so severe that it's obvious something isn't right. Other people feel generally miserable or unhappy without really knowing why.
Depression affects each person in different ways, so symptoms caused by depression vary from person to person. Inherited traits, age, gender and cultural background all play a role in how depression may affect you.
Depression symptoms in children and teens
Common symptoms of depression can be a little different in children and teens than they are in adults.
In younger children, symptoms of depression may include sadness, irritability, hopelessness and worry.
Symptoms in adolescents and teens may include anxiety, anger and avoidance of social interaction.
· Changes in thinking and sleep are common signs of depression in adolescents and adults but are not as common in younger children.
In children and teens, depression often occurs along with behavior problems and other mental health conditions, such as anxiety or attention-deficit/hyperactivity disorder (ADHD).
Schoolwork may suffer in children who are depressed.
Depression symptoms in older adults
Depression is not a normal part of growing older, and most seniors feel satisfied with their lives. However, depression can and does occur in older adults. Unfortunately, it often goes undiagnosed and untreated. Many adults with depression feel reluctant to seek help when they're feeling down.
· In older adults, depression may go undiagnosed because symptoms — for
example, fatigue, loss of appetite, sleep problems or loss of interest in sex —
may seem to be caused by other illnesses.
· Older adults with depression may have less obvious symptoms. They may feel
dissatisfied with life in general, bored, helpless or worthless. They may always
want to stay at home, rather than going out to socialize or doing new things.
· Suicidal thinking or feelings in older adults is a sign of serious depression that
should never be taken lightly, especially in men. Of all people with depression,
older adult men are at the highest risk of suicide.
When to see a doctor
If you feel depressed, make an appointment to see your doctor as soon as you can. Depression symptoms may not get better on their own — and depression may get worse if it isn't treated. Untreated depression can lead to other mental and physical health problems or problems in other areas of your life. Feelings of depression can also lead to suicide.If you're reluctant to seek treatment, talk to a friend or loved one, a health care professional, a faith leader, or someone else you trust.
If you have suicidal thoughts
If you or someone you know is having suicidal thoughts, get help right away. Here are some steps you can take:
Contact a family member or friend.
- Seek help from your doctor, a mental health provider or other health
· Call a suicide hot line number — in the United States, you can reach the
toll-free, 24-hour hot line of the National Suicide Prevention Lifeline at
800-273-8255 to talk to a trained counselor.
· Contact a minister, spiritual leader or someone in your faith community.
When to get emergency help
If you think you may hurt yourself or attempt suicide, call 911 or your local emergency number immediately. If you have a loved one who has harmed himself or herself, or is seriously considering doing so, make sure someone stays with that person. Take him or her to the hospital or call for emergency help.
(info taken from
Causes of Depression
According to the Medical Model
It's not known exactly what causes depression. As with many mental illnesses, it appears a variety of factors may be involved. These include:
· Biological differences. People with depression appear to have physical changes
in their brains. The significance of these changes is still uncertain, but may
eventually help pinpoint causes.
· Neurotransmitters. These naturally occurring brain chemicals linked to mood
are thought to play a direct role in depression.
· Hormones. Changes in the body's balance of hormones may be involved in
causing or triggering depression. Hormone changes can result from thyroid
problems, menopause or a number of other conditions.
· Inherited traits. Depression is more common in people whose biological family
members also have this condition. Researchers are trying to find genes that
may be involved in causing depression.
· Life events. Certain events, such as the death or loss of a loved one, financial
problems, and high stress, can trigger depression in some people.
· Early childhood trauma. Traumatic events during childhood, such as abuse or
loss of a parent, may cause permanent changes in the brain that make you
more susceptible to depression.
Where Depression comes from:
The Cognitive-Behavioral Equation:
The Behavioral Process
(according to the Cognitive Behavioral Therapy equation)
Our thoughts/beliefs = our feelings = our behaviors
Positive thoughts/beliefs = positive feelings = positive behaviors
Negative thoughts/beliefs = negative feelings = negative behaviors
Therefore, our thoughts/beliefs = our reality
All negative thoughts/beliefs come from trauma,
either real or perceived
Cognitive-Behavioral Therapy Distortion Checklist
1. All-or-nothing thinking: You restrict possibilities and options to only two choices: yes or no (all or nothing).
2. Over generalization: You view a single, negative event as a continuing and never-ending pattern of defeat.
3. Negative Mental filter: You dwell mostly on the negatives and generally ignore the positives. This is like the drop of ink that discolors the entire beaker of water.
4. Discounting the positives: You insist your achievements or positive efforts do not count.
5. Jumping to conclusions:
5a. Mind-reading: You assume people are reacting negatively to you w/o any objective
5b. Fortune-Telling: You pr edict things will turn out badly w/o objective any evidence.
6. Magnification or minimization: You blow things way out of proportion or minimize their importance.
7. Emotional reasoning: You base your reasoning from your feelings: "I feel like a loser, so I must be one.
8. "Mustabatory thinking" or "Shoulding All Over Yourself": You criticize yourself or other people with "musts," "shoulds," "oughts," and "have tos."
8a. Self-Directed Shoulds lead to feelings of guilt and inferiority.
8b. Other-Directed Shoulds lead to feelings of bitterness, anger and frustration.
9. Labeling: Instead of saying "I made a mistake," you tell yourself "I'm an idiot" or "I'm a loser."
10. Personalization: You blame yourself almost completely for something for which you were not entirely responsible.
10a. Self-Blame and Other-Blame. You find fault instead of solving the problem.
10b. Self-Blame. You blame yourself for something you weren't entirely responsible for.
10c. Other-Blame. You blame others and overlook ways you contributed to the problem.
Or, another way to put it is:
The ABC’s of Behavior
(from Albert Ellis’ Rational Emotive Behavior Therapy)
A > B > C
The Your The
Activating Beliefs Consequences
Event about (your feelings
this event & behaviors)
^ ^ ^
The “Pushers” Your “Buttons” The Consequences
of your “Buttons” of your “ Buttons”
(What pushes (What are (How did you express
your “Buttons”?) your “Buttons”?) yourself when your
buttons were pushed?)
Rational Emotive Behavior Therapy (R.E.B.T.) also has their own list of Irrational thinking/beliefs that cause our negative thinking, negative feelings and negative/dysfunctional behaviors.
12 Irrational Ideas That Cause and Sustain Neurosis
Rational Emotive Behavior Therapy holds that certain core irrational ideas, which have been clinically observed, are at the root of most neurotic disturbance. They are:
1. The idea that it is a dire necessity for adults to be loved by significant others for almost everything they do - instead of their concentrating on their own self‑respect, on winning approval for practical purposes, and on loving rather than on being loved.
2. The idea that certain acts are awful or wicked, and that people who perform such acts should be severely damned - instead of the idea that certain acts areself‑defeating or antisocial, and that people who perform such acts are behaving stupidly, ignorantly, or neurotically, and would be better helped to change. People's poor behaviors do not make them rotten individuals.
3. The idea that it is horrible when things are not the way we like them to be instead of the idea that it is too bad, that we would better try to change or control bad conditions so that they become more satisfactory, and, if that is not possible, we had better temporarily accept and gracefully lump their existence.
4. The idea that human misery is invariably externally caused and is forced on us by outside people and events ‑ instead of the idea that neurosis is largely caused by the view that we take of unfortunate conditions.
5. The idea that if something is or may be dangerous or fearsome we should be terribly upset and endlessly obsess about it - instead of the idea that one would better frankly face it and render it non‑dangerous and, when that is not possible,accept the inevitable.
6. The idea that it is easier to avoid than to face life difficulties and self responsibilities, instead of the idea that the so‑called easy way is usually much harder in the long run.
7. The idea that we absolutely need something other or stronger or greater than ourselves on which to rely - instead of the idea that it is better to take the risks of thinking and acting less dependently.
8. The idea that we should be thoroughly competent, intelligent, and achieving in all possible respects - instead of the idea that we would better do rather than always need to do well and accept ourselves as a quite imperfect creature, who has general human limitations and specific fallibilities.
9. The idea that because something once strongly affected our life, it should indefinitely affect it - instead of the idea that we can learn from our past experiences but not be overly attached to or prejudiced by them.
10. The idea that we must have certain and perfect control over things - instead of the idea that the world is full of probability and chance and that we can still enjoy life despite this.
11. The idea that human happiness can be achieved by inertia and inaction instead of the idea that we tend to be happiest when we are vitally absorbed in creative pursuits, or when we are devoting ourselves to people or projects outside ourselves.
12. The idea that we have virtually no control over our emotions and that we cannot help feeling disturbed about things - instead of the idea that we have real control over our destructive emotions if we choose to work at changing the masturbatory hypotheses which we often employ to create them.
Common Types of Depression
There are several types of depression. Very briefly, they are:
· Major depression — a depressed mood that lasts for more than two weeks with distinct symptoms related to eating, sleeping, concentrating and more.
· Dysthymia — a chronic, low-grade form of depression that is not as severe as major depression.
· Seasonal Affective Disorder (SAD) — a pattern of depression that comes and goes with the change in season, usually occurring in the fall and winter.
· Postpartum depression — a serious depression that some women experience after childbirth.
· Bipolar disorder — a mood disorder in which people have extreme mood swings that include intense emotional highs (manias) and lows (depression). It requires a different treatment approach than depression does.
· Adjustment disorder — a depressed mood that occurs after a particularly stressful event.
· Depression with psychosis — a very serious but uncommon condition in which people have delusions or hallucinations along with depression symptoms.
(info taken from
Dysthymic Disorder (or 'dysthymia') is often characterised by chronic (long term, ongoing) depression, but without the severity of major depression.
The symptoms of Dysthymia are the same as for depression, however usually not as severe as major depression, AND an almost daily depressed mood for at least two years. Other symptoms often include lowered energy, sleep and appetite disturbances and low self-esteem.
Sufferers of Dysthymic Disorder will often claim that they can't ever remember NOT feeling depressed!
Dysthymia does not tend to debilitate the sufferer to the point where they cannot perform everyday routines, although the disorder is severe enough to cause distress and interference with important life relationships, roles and responsibilities.
Dythysmic Disorder causes changes in thinking, feelings, behaviour and physical well-being.
Changes in Thinking Sufferers are likely to experience concentration and decision making difficulties, as well as problems with short term memory and forgetting things all the time. Negative thoughts, pessimism, lowered self-esteem, guilt and self-criticism are all characteristic of Dysthymic Disorder.
Changes in Feelings Feeling sad for no reason and no longer enjoying activities that you used to, lack of motivation, apathy, lethargy and irritability are all of the feelings that you may be experiencing if you suffer from Dysthymic Disorder. Dysthymic Disorder can also lead to feelings of helplessness and hopelessness.
Changes in Behavior Sufferers may experience social withdrawal, changes to eating habits (either eating more or less), excessive crying, a pessimistic attitude to everything, anger and temper outbursts, loss of libido, neglecting personal appearance or hygiene.
Changes in Physical Well-being Chronic fatigue, loss of appetite, slowing down and aches and pains are all extremely common physical aspects of Dysthymic Disorder. Although all of these physical symptoms would have a debilitating affect on the sufferers life, fatigue appears to be the major cause of these problems. The sufferer may go to bed earlier, or stay in bed longer, but the amount of sleeping that the person is getting does not add up to the amount that they need.
There are many different treatments available for sufferers of Dysthymic Disorder, and a combination of psychotherapy and antidepressants seem to be the way to go at the moment. As always, it is best to discuss your treatment with your doctor or other health care professional. There are also some lifestyle changes that may help. .
POST NATAL DEPRESSION
Postnatal Depression is actually more common than many people realise and occurs in about 80 per cent of women after child birth.
The feeling of the 'baby blues' often passes within two days, but if it continues then this is what is known as postnatal depression (PND).
Postnatal Depression usually occurs within the first 12 months of having a baby, often within the first few weeks or months. The severity of the depression can range from very mild and almost non-existent, to very severe and long-term and tends to be most common after the first pregnancy.
Some women experience depression during pregnancy, this is called ante natal depression.
The most common symptoms that you are likely to experience with PND are; Lowered self-esteem and a lack of confidence, guilt, inadequacy, negative thoughts, pessimism, feelings that life is meaningless, irritability, tearfulness, feelings of inability to cope, sleeping problems, lowered libido, anxiety, panic attacks, heart palpitations, loss of appetite, and difficulties in remembering or concentrating on things.
Not every woman will experience all these symptoms as it depends on the severity of the depression.
Although the exact cause of PND is not yet known some of the contributing factors may be:
Giving birth, easy or not, is a major experience for the female body and the sudden change in hormones affects the brain's chemical balance. The fact that there is a new born child around that needs attention also means that women are less likely to be able to get the sleep that they need. becoming exhausted and trying to adapt to broken sleep does not help the mother get through the initial depression that they may experience.
The adaptation process that new mothers have to take is made increasingly harder by the fact that there is a new born to be looked after. Recovery is made harder by underlying factors such as; broken sleep, changed relationship with a partner, loss of independence, and the constant demands of the child can sometimes become far too overwhelming for some women after childbirth.
The social stigma surrounding childbirth makes adjusting to this new addition extremely hard, the new mother may find herself losing contact with her friends and learning to live off one wage makes the situation even harder.
SEASONAL AFFECTIVE DISORDER
Seasonal Affective Disorder or S.A.D has not yet been classified as a distinct psychological disorder.
S.A.D tends to affect most people throughout their life and some of us probably don't even know it. It seems to be that with the changing of seasons peoples moods will change, depending on the amount of sunlight or rain there is.
The most common times of year for people to slip into a depressive state is winter. The days are shorter and colder, its bleaker and more unpleasant outside. The sufferer becomes a vegetative depressive, not wanting to do anything much at all. The sufferer will tend to eat more and sleep more, experience chronic fatigue and gain weight. In some extreme cases of S.A.D the sufferer can also have significant social withdrawal.
Eventually, with the onset of spring the sufferer comes out of 'hibernation' and depending on circumstances improvement is almost immediate.
However in some people the effect of S.A.D. can be quite severe, and bring about symptoms of depression that interfere with normal daily functioning. The good news is that it is usually able to be appropriately treated with very minimal effort or side-affects.
Research is still being carried out in this area of depression to find out if Seasonal Affective Disorder is due to the seasons or if it is a recurrence of major depression or another mood disorder, which is triggered or exaggerated by the changing seasons. There has been some study done using sunlight. Sunlight entering through the retina stimulates the production of chemicals in the brain that appear to have an antidepressant affect, this form of therapy is also known as 'Bright Light Therapy' or BLT.
Seasonal Affective Disorder appears more prevalent in people who are younger, live at higher latitudes ie; further North, and in (generally speaking) women.
People who are young: it is unknown yet whether S.A.D affects younger people more often because of a biological pattern, related to age, or if it is just the way that younger people tend to describe the depression that they may suffer from.
People who live at higher latitudes: more Northern countries and states tend to have less sunlight, with harsher winters that produce colder conditions and frequent storms.
People of different genders: women are more likely to be diagnosed with S.A.D than men, the most reasonable answer to this would be that more women are diagnosed with depression than men. Another possible reason for this could be that women with small children tend to be more isolated during the winter months than those women with careers. Men are generally not left at home to look after small children and so it seems that another reason for S.A.D could be that if caretaking was an equally shared job then there may be less women diagnosed with S.A.D.
Depression often begins in the teens, 20s or 30s, but it can happen at any age. Twice as
many women are diagnosed with depression as men, but this may be due in part
because women are more likely to seek treatment for depression.
Although the precise cause of depression isn't known, researchers have identified
certain factors that seem to increase the risk of developing or triggering depression,
- Having biological relatives with depression
· Being a woman
· Having traumatic experiences as a child
· Having family members or friends who have been depressed
· Experiencing stressful life events, such as the death of a loved one
· Having few friends or other personal relationships
· Recently having given birth (postpartum depression)
· Having been depressed previously
· Having a serious illness, such as cancer, diabetes, heart disease, Alzheimer's or
· Having certain personality traits, such as having low self-esteem and being
overly dependent, self-critical or pessimistic
· Abusing alcohol, nicotine or illicit drugs
· Taking certain high blood pressure medications, sleeping pills or certain other
medications (Talk to your doctor before stopping any medication you think
could be affecting your mood.
Depression is a serious illness that can take a terrible toll on individuals and families. Untreated depression can result in emotional, behavioral and health problems that affect every area of your life. Complications associated with depression can include:
- Alcohol abuse
· Substance abuse
· Work or school problems
· Family conflicts
· Relationship difficulties
· Social isolation
· Self-mutilation, such as cutting
· Premature death from other medical conditions.
(most of the above information was taken directly from
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Bipolar Disorder (once called 'manic depression') tends to be associated with alternating low, depressive moods and high or 'manic' moods separated by periods of 'normal' moods.
However, it is not uncommon for these depressive moods to be accompanied by manic moods at the same time. These two extremes of bipolar disorder can also rapidly change from day to day or even from hour to hour.
We all have mood swings from time to time, and this is healthy when our mood reflects what is happening in our lives. It is only when these mood swings – either highs or lows – interfere with, or cause problems within, our daily life and are not related to external events or situations that they may be due to the clinical condition called Bipolar Disorder and need professional treatment.
There are 2 forms of bipolar disorder: Bipolar 1 disorder and Bipolar 2 disorder (not very creative names!) Bipolar 1 disorder tends to involve extended high periods and also may include psychotic episodes, whereas Bipolar 2 disorder does not involve psychotic episodes and the periods of mania tend to be shorter, ie from a few hours to a few days at a time.
NOTE: Bipolar Disorder is one of the most mis-diagnosed / undiagnosed mental illnesses. It is important to talk to your doctor about this if you think that you may have bipolar disorder rather than depression.
There is a very interesting research article regarding the importance of checking for bipolar disorder.
Below we have more information on Bipolar 1, Bipolar 2, manic & depressive episodes, as well as Our Stories from people living with Bipolar Disorder.
The Black Dog Institute in NSW has some excellent detailed information about Bipolar Disorder on their website at: They also provide very useful information for GPs on bipolar disorder including how to best treat / manage this condition. With new research being done all the time, and bipolar disorder often missed in diagnosis, it can't hurt to let your GP know and suggest they have a look!
Bipolar 1 Disorder
Bipolar 1 Disorder is also known as Bipolar 1 or Bipolar Type 1.
This is considered to be the most severe form of bipolar disorder and is characterised by one or more Manic or Mixed Episodes, usually accompanied by Major Depressive Episodes.
In a major manic episode of Bipolar 1 Disorder a person may become delusional and even suffer from hallucinations, which are both symptoms of psychosis. If this occurs, the condition is called bipolar I with psychotic features. Only bipolar I disorder, by definition, can include psychotic features. Bipolar I can seriously impair day-to-day functioning.
Other symptoms and characteristics of mania may include:
Feelings of grandiosity
Decreased need for sleep
Tendency to engage in behavior that could have serious consequences, such as spending recklessly or inappropriate sexual behaviors
Symptoms and characteristics of major depression in Bipolar 1 Disorder are the same as those for major depression and may include:
Severe withdrawal from normal activities
Weight loss or gain
Thoughts of or attempts at suicide
For a very clinical definition, the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) clinical diagnostic criteria states that the essential feature of bipolar I disorder is a clinical course that is characterized by the occurrence of one or more manic episodes or mixed episodes. Often individuals have also had one or more major depressive episodes.
Episodes of substance-induced mood disorder due to the direct effects of a medication, or other somatic treatments for depression, drug abuse, or toxin exposure, or of mood disorder due to a general medical condition need to be excluded before a diagnosis of bipolar I disorder can be made. In addition, the episodes must not be better accounted for by any other disorder.
Bipolar 2 Disorder
Bipolar 2 Disorder is also known as Bipolar 2 or Bipolar Type 2.
This is a bipolar disorder that is characterized by at least one hypomanic episode and at least one major depressive episode and with this disorder the depressive episodes are more frequent and more intense than the manic episodes.
Bipolar 2 disorder is believed to be under-diagnosed because hypomanic behavior often presents as incredibly high-functioning behavior. Sometimes even mental health professionals specialising in mood disorders may view, highly confident ambition to be symptomatic of hypomania only if they consider that person's goals are unrealistic.
There is an interesting article on the incidence of undiagnosed or misdiagnosed Bipolar Disorder written by Professor Gordon Parker of the Black Dog Institute in N.S.W.
The key difference between bipolar 1 and bipolar 2 disorders is that bipolar 2 has hypomanic but not manic episodes, meaning the symptoms of mania are generally less severe in type 2.
Also, while those with bipolar 1 disorder may experience additional psychotic symptoms such as delusions and hallucinations, bipolar 2 by definition cannot have psychotic features.
The signs which would lead to a diagnosis of bipolar 2 disorder are:
One or more major depressive episodes
At least one hypomanic episode
There has never been a manic or mixed episode
Another disorder is not responsible for symptoms
Symptoms cause distress or impair functioning
The manic stage of bipolar disorder shares the underlying common characteristics of an elevated mood, and is characterized by an increase in the quantity and speed of physical and mental activity.
The person experiencing hypomania may also become more sociable, talkative, over-friendly, have an increased sexual energy and a decrease in the amount of sleep needed. Even though these are present they do not necessarily lead to a disruption in working or in a disruption in social activity. The opposite of this elevated feeling may also take place leaving the sufferer irritable, conceited and boring.
Their concentration and attention may be impaired, thus leading to work, leisure and relation difficulties. Whether on a slightly elevated or slightly lower hypomania the sufferer may have a new interest in adventures, activities or mild over-spending.
Hypomania is a lesser degree of mania. The distinctiveness of mania is no longer present and a more consistent mood is prevalent. Hypomania does not include hallucinations or delusions, but is a mild elevation in mood that can last several days on end. It is usually recognised by the distinct increase in energy and activity, as well as feelings of well-being and both physical and mental efficiency.
Depressive episodes can be classed as either one of the following; mild, moderate or severe.
When the sufferer is in the depressive episode they may suffer loss of interest and enjoyment, reduced energy, fatigue, lethargy, apathy, depressed mood, lowered concentration and attention, reduced self-esteem and self-confidence, guilt, unworthiness, become pessimistic, diminished sleep and appetite and ideas or acts of self-harm or suicide.
Depressive episodes can often be masked by irritability, excessive consumption of alcohol, obsessional symptoms and hypochondria. The most typical symptoms are: loss of interest or pleasure in activities that are normally enjoyable, lack of emotional reactivity, waking in the early morning hours, loss of appetite and weight loss or gain and loss of libido.
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Cyclothymic Disorder usually develops early in adult life leading to a chronic course of mood swings that vary from mild elation to mild depression. These mood swings, either elation or depression, can last for several months and become a stable mood then the mood can change.
Due to the mildness of the mood changes the person suffering from Cycloythmia will rarely bring it to medical attention. There are often changes in appetite, self-confidence, activity and sociability. Cycloythmic Disorder is most common in relatives of people who suffer from bipolar affective disorder, and some people who have cycloythmic disorder can develop bipolar affective disorder.
Cycloythmic Disorder may persist throughout adult life, either temporarily or permanently ceasing, or becoming more severe in mood swings, eventually leading to bipolar affective disorder or recurrent depressive disorder.
'Severity' of depression
Defining the 'degree' or 'severity' of depression (i.e., if it is mild, moderate or severe), requires an extensive medical judgement that involves the number, type, and severity of the symptoms present.
Mild depression usually causes symptoms that are detectable and impact upon our daily activities. We are less interested in doing things we previously enjoyed, unusual irritability, reduced motivation in work, home or social activities are common however we continue to function – just perhaps not as well as we normally would do when healthy.
Mild depression often goes undiagnosed because the symptoms are not considered to be 'bad enough' for people to think they may have depression and discuss it with their doctors or other people. However accurately diagnosing depression when it is mild, and treating it effectively at this stage can prevent the condition from worsening to become moderate or severe.
There are also more treatment options available for mild depression. Lifestyle changes such as regular exercise, relaxation, ensuring sufficient and regular sleep, etc are often sufficient. Natural therapies such as St John's Wart may also be effective treatments for depression if it is diagnosed early – when 'mild'.
Moderate depression can cause real difficulties with social, work and domestic activities. The characteristics described for mild depression are worse here – by definition. A reduced interest in normally pleasurable activities becomes no interest – a real lack of interest and motivation. Simple things start to require real effort or just get neglected.
With moderate depression there is usually a detectable reduction in self confidence and/or self esteem which can have a 'snowball' effect as we become less motivated and hence less productive. Often we start to worry about things unnecessarily such as performance at work, even if we are managing to maintain our previous standards, or more sensitive and susceptible to feeling hurt or offended within personal relationships.
Again, there are more treatment options available and the time it will take to recover from moderate depression will be less than if it is left untreated and develops into major depression. Cognitive Behavioral Therapy (C.B.T.) can be very effective and some natural therapies may still be helpful, although it is essential that you discuss this with your doctor to ensure you use the most effective treatment option and don't waste time, money and energy on treatments that aren't doing anything. This only gives the illness an opportunity to worsen as it is not being effectively treated.
If medication is required, you are likely to be need a lower dose for moderate depression than for major depression. Lifestyle improvements always have a positive impact, however can take more effort to actually do as the depression becomes more severe.
Severe or Major depression causes considerable distress or agitation, loss of self-esteem or feelings of uselessness and guilt. We are unlikely to be able to continue with work, social and domestic activities. Severe (or Major) depression usually causes severe enough symptoms for a change to be noticeable by those around us even if we try to mask how we are feeling. A person with major depression will usually experience most, if not all of the symptoms listed on 'Symptoms of depression'.
Suicide is a distinct and major danger. While we may be managing one moment, we can plummet very quickly into feelings of hopelessness and despair. It is common for people to feel that they are somehow responsible and 'to blame' for the way thery are feeling and believe that others are better off without them.
At this level, it is vital that professional help and treatment is sought as soon as possible and that treatment is adhered to. As with all major illnesses, during major depression we need additional support on a daily basis both in managing the symptoms and to provide help with treatment.
People with severe depressive episodes may also suffer from delusions, hallucinations or depressive stupor although these are less common.
Forms of Treatment for Depression
The recommended treatment for depression is a combination of antidepressant medication and therapy - either cognitive behavioral therapy (C.B.T.) or Interpersonal Relationship Therapy (IPT).
There is also a range of natural and other treatments as well as tools and techniques, that many people have found very useful in treating and/or managing their depression.
The Established Treatments for Depression
Cognitive Behavioral Therapy
Cognitive Behavioral Therapy is...
C.B.T. does not necessarily aim to solve every problem in your life. Instead, C.B.T. aims to teach you the skills so you can better solve your own problems now, and in to the future. C.B.T. focuses mostly on the "here and now", and particularly on the way you think about things (including your attitudes and beliefs).
Cognitive behavior therapy works by helping you identify where your thoughts (and actions) are unhelpful and self-defeating. Once aware of these issues, a cognitive behavior therapist will help you to replace these negative thoughts and "bad habits" with more helpful thoughts and more constructive behaviors. There are various strategies for achieving this, including asking for feedback from other people and weighing up the pros and cons of different options.
C.B.T. is a collaborative process based on understanding, empathy, support and most importantly, a strong belief that you can change – for the better.
By focusing on thoughts, attitudes, beliefs and behaviors C.B.T. has been proven to be the most effective intervention for problems such as depression, anxiety, panic, stress, insomnia, relationship difficulties and even coping with chronic illness (such as pain). Much can be achieved with C.B.T. including feeling really great about life, instead of just okay.
Role of Psychotherapy
The generally accepted preferred treatment for depression is a combination of psychotherapy and antidepressant medication. While in the above discussion, the focus has been on issues relating to antidepressant medication, psychotherapy plays an important role in treating depression.
Professor Keller presented the following important research results comparing:
Medication alone – 50% experience elimination of symptoms in 10 weeks
Therapy alone – 50% experience elimination of symptoms in 10 weeks
Medication + Therapy – 85% experience elimination of symptoms in 10 weeks
Note that the 'therapies' used in this study were Cognitive Behavioral Therapy and Interpersonal Relationship Therapy – as appropriate for the particular person.
The role of therapy in ongoing maintenance was not investigated, but it does make sense to ensure that the skills and techniques we learn during the initial therapy be reinforced and continually practiced not only during treatment, but beyond and into our healthy lives!
Medical Treatments for Depression
The current proven most effective treatment for depression is a combination of antidepressant medication and therapy – usually Cognitive Behavioral Therapy (C.B.T.)
It is very important to discuss your personal treatment with your GP or other health care professional that you trust and can work with to find the best treatment approach for you.
Here we provide both factual information, and thoughts from other 'people like us' who have depression and from experts, on some of the most common questions and issues around antidepressant medication.
Do I need to take antidepressants?
Finding the right antidepressant medication for you
How long will I need to take antidepressant medication?
Will I recover from depression? Will it return?
How do antidepressant medications work?
Types (categories) of antidepressant medication
A list of antidepressant medication with links through to the Consumer Medicine Information (CMI)
Sex and Antidepressants - an article on issues with medication and sexual function
ELECTRO CONVULSIVE THERAPY (ECT)
Electro Convulsive Therapy (ECT) can be an effective therapy for very severe depression, but it would probably only be considered if you were bad enough to be hospitalised for your depression. The treatment involves administering, under anaesthetic, a series of electric shocks to the brain at intervals over a few weeks. Many complain of memory loss following ECT.
There has been fairly minimal research done using ECT as a form of treatment for depression. In the research that has been done children and adolescents have rarely been included beacuse of unproven fears that ECT may damage the developing brain.
In a research done by Rey and Walter, of 396 adolescents and children who recieved elctroconvulsive therapy, improvement rates were of 80% for catatonia, 80% for mania and 63% for depression. These results were given after all other forms of antidepressant treatments had been used.
Improvments have been seen in tests using ECT in patients with psychotic depression, bipolar affective disorder and psychosis.
In an Australian experience with ECT between 1990 and 1996, 42 patients (aged 14 – 18) underwent 49 courses of ECT comprising of 450 treatments. Symptoms improved in half the completed courses, especially in patients with mood disorders, with transient side effects.
The adverse effects of ECT have been fracture, panic episodes, fear, spontaneous seizures and headaches. These side effects are avoided these days by using anethesia, muscle relaxation, oxygenation, brief-pulse stimulating currents, selected electrode placement and energy dosing. The primary impact of ECT remains its effect on recall and learning.
Adults often have vague recollections of events and experiences that occured during their illness. Some patients report more persistent memory difficulties.
Generally speaking ECT is used as a 'last resort', especially on children and adolescents, and only after all other first-line therapies and treatments have failed to help.
VAGUS NERVE STIMULATION (VNS)
The Vagus Nerve Stimulator (VNS) has been researched for around 20 years. This "pacemaker for the brain", acts as a stimulator for the vagus nerve. The vagus nerve is defined as the nerve that produces inhibition of neural processes, which can alter the brain electrical activity.
Medical treatment for depression has included over the years, neurosurgery, electroconvulsive therapy, transcrainal magnetic stimulation, and anti-depressant medication.
VNS was first considered for treatment-resistant depression because:
clinical observations of improved cognition and mood during studies of patients with epilepsy .
the fact that several anti-convulsant medication are used to treat mood disorders.
The most common side effects that have been reported in research studies and clinical trials as possibly, probably, or definitely related to stimulation were hoarseness, throat pain, headache, shortness of breath, general pain, and neck pain.
In general, stimulation-related effects were mild and well tolerated, and they have occurred only when stimulation was on. Hypomania has been caused through Vagus Nerve Stimulation, but has subsided with stimulation reduction.
In research studies and clinical trials responses occurred between 1 and 10 weeks following the initiation of stimulation.
For practicality all studies in humans, Vagus Nerve Stimulation refers to stimulation of the left cervical vagus nerve using a commercial device.
In many ways, VNS is much like the very common practice of implanting cardiac pacemakers. In both cases, a generator sends an electrical signal to an organ through an implanted electrode.
Vagus Nerve Stimulation is delivered through an implantable, multiprogrammable, bipolar pulse generator ( the size of a pocket watch) that is implanted in the left chest wall to deliver electrical signals to the left vagus nerve through a bipolar lead. With VNS, the electrode is wrapped around the vagus nerve in the neck, near the carotid artery using a separate incision, and then connected to the generator.
The software, along with a personal computer, provide telemetric communication with the pulse generator, which enables noninevasive programming, functional assessments and data retrieval. The system includes mechanical and electrical safety features that minimise the possibility of high-frequency stimulation that could lead to tissue damage. In addition, each patient is given a magnet that, when held over the pulse generator, turns off stimulation. When the magnet is removed, normal programmed stimulation resumes.
The possible side-effects that have been reported at some time during treatment that were significantly increased, were voice alteration/hoarseness, cough, throat pain, nonspecific pain, dyspnoea, paraesthesia, dyspepsia, vomiting and infection. No cognitive, sedative, visual, affective, or coordination side effects have been reported.
Jolted Out Of Major Depression By: Robert Davis, USA TODAY
REPETITIVE TRANSCRANIAL MAGNETIC STIMULATION (RTMS)
Repetitive transcranial magnetic stimulation (rTMS) is a new technology that is showing promise as a treatment for depression.
rTMS involves holding an insulated coil in contact with the scalp and passing a strong current around the coil. This creates a magnetic field that passes through to the brain. When the current is rapidly fluctuated, the magnetic field fluctuates causing tiny secondary currents in the brain.
ECT is regarded as the most powerful antidepressant available (Abrams, 1997), and a study conducted by Professor S Pridmore at the Royal Hobart Hospital in Tasmania, suggests that under certain circumstances, rTMS can achieve results similar to ECT, without the impact on memory that ECT has. There is a link to the research article in the International Jornal of Neuropsychopharmacology below.
DEEP BRAIN STIMULATION
Deep Brain Stimulation (DBS) has been successfully used to treat people with Parkinson's disease, multiple schleroses and tourettes, however is a relatively new treatment option for depression. It is usually only considered an option for those for whom other treatments have been unsuccessful.
Below we have links to research papers (the last two here can be heavy reading), and some more recent Australian articles that refer to clinical research studies.
There are also Research Projects that are needing participants for DBS and this can be a great way to access treatment!
A video article on the internet from a Today Tonight program (31st January 2012)
A little more reader friendly than the two articles below; the Scientific American, has a blog entry Deep Brain Stimulation for Major Depression: Miracle therapy or just another treatment? (9th January 2012).
An article on Deep Brain Stimulation that was published in The Age in March 2011.
Deep Brain Stimulation for Treatment Resistant Depression is a clinical study at Toronto University of 6 patients who received the treatment and was published in 2005 in Neuron v45.
Subcallosal Cingulate Gyrus Deep Brain Stimulation for Treatment-Resistant Depression was published on neurosurgerytoday.org and is summarised as "A preliminary report in six patients (study above) suggested that deep brain stimulation (DBS) of the subcallosal cingulate gyrus (SCG) may provide benefit in treatment-resistant depression (TRD). We now report the results of these and an additional 14 patients with extended follow-up."
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