UNM COC:  Your Healthcare Primer for Long Term Care

 
Depression

Judith Stevens M.Ed. 

With thanks to Jennifer Thorne-Lehman, and Araceli Domingo for contributing resource information.

Definition

Depression is a mood disorder that affects a person’s thoughts, body, and mood. People who are depressed can experience "down" feelings such as sadness and hopelessness. It’s different from normal emotions in reaction to real events such as grief after a loved one dies or losing a job. What makes it different is that a depressive disorder involves the whole person and is not a passing unhappy mood. The symptoms of depression can last a long while – in fact, that’s part of the way it can be diagnosed. Depression may also start without a clear cause but often a combination of genetic, environmental and psychological factors play a part in depressive disorders.

Introduction

The National Institute of Mental Health estimates that 10% of the population experience depressive disorders.

There are different types of depressive disorders:

• Major depression involves a variety of symptoms that make it hard to work, sleep, eat, and enjoy what the person would normally enjoy. A major depressive episode involves at least two weeks where the person has a depressed mood or loses interest or pleasure in nearly all activities.

• Mild depression (dysthmia) is less a less severe form of depression but still involves chronic and long-standing symptoms. People are more able to carry on with life but without feeling good. A person who has mild depression can sometimes also slip into major depression.

• Bipolar disorder (formerly called manic depression) is a less common depressive disorder. A person with bipolar disorder moves from cycles of depression to manic periods of being elated and very energized. Moods may switch quickly but the change is usually more gradual. When a person is manic they may use poor judgment and think they can do unrealistic things.

• Another aspect of depressive disorder is often referred to as seasonal affective disorder (SAD) when a depressive disorder is linked to certain seasons of the year (for example, in seasons with little sunlight).

A family history of depressive disorder increases the risk of developing depression but not everyone with this risk develops the disorder. In fact, depressive disorder can happen in someone whose family has no history of depression. Whether it comes through a family connection or not, people with major depressive disorder often have an imbalance in certain chemicals in the brain called neurotransmitters.

A "unwelcome change in life patterns" (NIMH, date unknown) can play a part in triggering depression.

What a person puts into their body can also affect depressive disorders. For example, too much alcohol can make a person’s antidepressant medication less effective. As another example, initial research has indicated that using the artificial sweetener, aspartame, might not be a good idea for someone with a history of depression.

Even a person’s age or gender may affect risk for depression. More women are diagnosed with depression than men. Elderly people are also at risk of depression.

People with certain chronic illnesses (such as diabetes, multiple sclerosis, post stroke [cerebrovascular disease], and brain injury) are more susceptible to depressive disorders. Not only that, but the depressive disorder can affect the person’s immune system and ability to fight the illness.

Depression occurs more commonly in people with Down’s Syndrome than for other persons who are intellectually disabled but who do not have that condition.

With people who have learning disabilities (Moss, 2000), "increasing severity of challenging behavior was associated with increased prevalence of psychiatric symptoms, depression showing the most marked association."

Research has also shown that facial neuromuscular disorders with a specific impairment to smiling was a "key predictor" (VanSwearingen, 1999) of depression.

Diagnosis

A diagnosis of depression should be made by a qualified, licensed mental health professional.

The DSM-IV (1994) describes a major depression as involving "a period of at least 2 weeks during which there is either depressed mood or the loss of interest or pleasure in nearly all activities." In addition, the person must also be experience at least four of the following symptoms (either new or worsened from the person’s previous status and, again, present for at least 2 consecutive weeks):

• Changes in appetite or weight, sleep, and psychomotor activity

• Decreased energy

• Feelings of worthlessness or guilt

• Difficulty thinking, concentrating, or making decisions

• Recurrent thoughts of death or suicidal ideation, plans or attempts

Again from the DSM-IV (1994), a mild (dysthymic) and a major depressive disorder are "differentiated based on severity, chronicity, and persistence".

The DSM-IV describes different types of bipolar disorders involving various combinations of depressive and manic episodes

For a "seasonal pattern specifier" (DSM-IV, 1994) to be added to a depressive disorder, a person must have had an pattern of depression and remission linked to certain seasons during the last two years without any non-seasonally linked episodes.

A. Gedye (1998) provides a useful "Checklist of Observable Signs of Depression" as a "guide for collecting information to aid in determining if the criteria for depression (e.g., DSM-IV, 1994) have been met. It is for use with developmentally disabled people who are unable to report their feelings." The Continuum of Care Project has made this book, Behavioral Diagnostic Guide, available in the Center for Developmental and Disability’s Resource Center.

One caution from Dr. Robert Fletcher (November, 2000): diagnosticians may fall prey to "diagnostic overshadowing" where the "…diagnostician overlooks or minimizes the signs of a psychiatric disturbance in a person with [an intellectual disability]." He also notes that 20-35% of all individuals with an intellectual disability have a psychiatric disorder which can contribute to reduced quality of life.

Prevention and Treatment

Since a combination of genetic, environmental and psychological factors play a part in depressive disorders, the exact cause of the depressive episode may be hard to pinpoint and thus prevent. The best prevention may be in gathering information and building wellness practices.

As with all wellness efforts, collecting on-going baseline information is important to getting a picture of what health looks like for that person. For example: What is normal appetite and weight for the individual? What are normal sleep patterns for the person? How and how much does the person usually communicate? What is the individual’s usual energy level?

This information collection can be used for comparison as well as to catch when a change occurs and clues as to why (Did a beloved family member die? Did a housemate move? Did the person develop a chronic illness?). Along with baseline information, it can also be helpful to identify any family history of depression to see if the person is at risk.

Another useful wellness activity is building strong relationships that can be a support network to an individual when stressful, unwelcome changes happen. Identifying personal vision and moving toward that vision is another way to build strong self-esteem and higher quality of life that the person can draw on in times of difficulty.

Education about choices and their consequences is another useful wellness effort. For example, a person can learn about the impact of alcohol and/or drug consumption.

A person can also develop a variety of ways to deal with normal stress that he/she can draw on when more serious stress occurs. For example, a person may deal with usual work stress by taking a walk or listening to favorite music at lunch.

For people who are susceptible to bouts of depression in seasons where there is little light, using full spectrum lights can be helpful during those seasons.

The first step in treatment is to get a full physical examination to identify and/or rule out other contributing factors (for example, pain). After a complete psychological examination has determined that the person has a depressive disorder, mental health professionals may use a variety of treatments from these two categories:

• antidepressant medication

• psychotherapies

The person can also help him/herself:

• learn about depression

• join a support group

• talk to and hang out with friends

• exercise every day

• not use drugs or alcohol

• break tasks into smaller parts

• do the things normally enjoyed

• learn the side-effects of any medications prescribed and report those to the doctor

• get out in the sunlight (with sun-screen or other protection) or exposure to full spectrum light daily

• use methods developed to help deal with stress

• call a suicide prevention network

Emergency Situations – What can go wrong?

As discussed above, certain medications prescribed for depressive disorder have side effects. For example, if a medication has a MAO inhibitor, the person may need to avoid certain foods such as coffee and chocolate, which could cause high blood pressure. Other medications may disrupt sleep or cause sun sensitivity.

A person with a depressive disorder may be at risk of suicide. In 1998, Kirchner reported that "people with DD are capable of suicidal behavior. Although suicidal ideations seem to occur more frequently than attempts, those that attempted utilized serious means with which to harm themselves." Kirchner also noted that only 50% of the suicidal group studied had a documented present or past history of suicidal behavior.

Any mention of suicide should be taken seriously and referred to a mental health professional.

Conclusion

Depression is a mood disorder that affects the entire person. There are different types of depressive disorder (major, mild [dysthymic], bipolar and other aspects). While the cause may be uncertain, generally it is caused by a combination of genetic, environmental and psychological factors. A licensed mental health professional can diagnose depressive disorder based on criteria specified in the DSM-IV. The best prevention may be in gathering relevant information and building wellness practices. Treatment by a licensed mental health professional may involve medication and/or therapy. The individual can also help themselves through activities such as exercising every day. A person with depressive disorder is at risk of side effects from certain medications and for suicide.

Direct Support Professionals can help by:

• learning about the symptoms and treatment of depression supporting the person to identify and reach their vision

• helping to identify and build the person’s desired quality of life

• supporting the person’s self-esteem

• assisting with links to support networks

• encouraging friend and family contacts

• educating about and encouraging wellness practices such as exercise, techniques to reduce stress, proper diet, avoiding alcohol and drugs

• gathering base-line information about the person and any family history of depression

• noting major life changes that might contribute to depression and bringing those to the attention of the Case Manager and Interdisciplinary Team

• assuring that the person diagnosed with depression is educated about depression and it’s treatment

• learning about, accommodating for (for example: avoiding prohibited foods or using sunscreen) and reporting potential side-effects of anti-depressant medication

• reporting any mention of suicide

References

American Psychiatric Association (1994). Diagnostic and Statistical Manual of Mental Disorders Fourth Edition: DSM-IV. Washington, D.C.: American Psychiatric Association.

Castleman, M (May 2000). The basics. Depression.com Memphis, Tennessee: PlanetRx.com

Castleman, M (May, 2000). Coping with depression. Depression.com Memphis, Tennessee: PlanetRx.com

Castleman, M (May, 2000). Tips for coping. Depression.com Memphis, Tennessee: PlanetRx.com

Castleman, M. Types of depression. Depression.com Memphis, Tennessee: PlanetRx.com

Castleman, M. "Who’s at risk for depression and why?. Depression.com Memphis, Tennessee: PlanetRx.com

Fletcher, R. J. (November, 2000). Information on Mental Health Aspects of Mental Retardation. New York: NADD. 

Fletcher, R. J., Schnieders, C., Ludwig, B., and Nagy-McNelis, D. (Editors, November 1998). NADD 15th Annual Conference Proceedings: Excellence from the Heart. New York: NADD Press.

Fukunishi, I., Aoki, T., and Hosaka, T. (December 1997). Correlations for social support with depression in the chronic poststroke period. Perceptual and Motor Skills. 85(3 part 1): 811-818.

Gedye, A. (1998). Behavioral Diagnostic Guide. Vancouver, Canada: Diagnostic Books.

Goldberg, I. K. (Revised: November, 2000). Alcohol and depression. Dr. Ivan’s Depression Central New York: Dr. Ivan’s Depression Central.

Goldberg, I. K. (Revised: November, 2000). Hints for speeding your recovery from depression. Dr. Ivan’s Depression Central New York: Dr. Ivan’s Depression Central.

Greenberg, D. and Oglesby, C (Spring, 1997). Physical activity and sport in the lives of girls: physical & mental health dimensions from an interdisciplinary approach. President’s Council on Physical Fitness and Sports Report. Minnesota: University of Minnesota, Supported by The Center for Mental Health Services/Substance Abuse and Mental Health Services Administration, U.S. Department of Health and Human Services. http://www.kls.umn.eddu/crgws/pcpfs/sxn4html 

Kirchner, L. and Mueth, M. (1998). Suicide in persons with developmental disabilities. NADD 15th Annual Conference Proceedings: Excellence from the Heart. New York: NADD Press.

Kripke, D. F. (May 1998). Light treatment for nonseasonal depression: speed, efficacy, and combined treatment. Journal of Affective Disorders. 49(2): 109-17.

Moss, S., Emerson, E., Kiernan, C., Turner, S., Hatton, C., and Alborz, A. (November, 2000). Psychiatric symptoms in adults with learning disability and challenging behavior. British Journal of Psychiatry. 177(5): 452-456.

National Institute of Mental Health (Note: no date given). Depression: What You Need to Know. Rockville, Maryland : U.S. Department of Health and Human Services, National Institute of Mental Health, National Institutes of Health. 

National Institute of Mental Health (1995). NIH Publication NO. 94-3590: Depression: Effective Treatments Are Available. Rockville, Maryland : U.S. Department of Health and Human Services, National Institute of Mental Health, National Institutes of Health. 

National Institute of Mental Health (1994). NIH Publication NO. 94-3561: Plain Talk About Depression. Rockville, Maryland : U.S. Department of Health and Human Services, National Institute of Mental Health, National Institutes of Health. 

VanSwearingen, J. M., Cohn, J. F, and Bajaj-Luthra, A. (November-December, 1999). Specific impairment of smiling increases the severity of depressive symptoms of patients with facial neuromuscular disorders. Aesthetic Plastic Surgery. 23(6): 416-23.

Walton, R. G., Hudak R. and Green-Waite, R. J. (July 1-15, 1993). Adverse reactions to aspartame. Biological Psychiatry. 34(1-2):13-7

Judith Stevens M.Ed.