Depression, a mental illness characterised by low mood (sad mood), is one of the most serious and common mental disorders. In your practice you will see many people with depression: as many as 1 in every 10 adults and possibly 1 in every 30 children that you see on your house-to-house visits may have depression.
It is normally easy to identify people with depression in your community. However, it is important to realise that low mood is also part of a normal human experience, and fortunately in most people low mood does not develop into a serious depression. In this session you will learn about the common presentations of depression, the common causes of depression and what you should do if you suspect depression in a person in your community.
When you have studied this session, you should be able to:
12.1 Define and use correctly all of the key words printed in bold. (SAQ 12.1)
12.2 Describe what depression is and how it commonly presents. (SAQs 12.1 and 12.2)
12.3 Describe the common causes of developing low mood. (SAQ 12.3)
12.4 Explain how you talk with someone who has depression. (SAQ 12.4)
12.5 State what to do if you suspect someone has depression. (SAQs 12.4 and 12.5)
Usually people’s feeling state (mood) varies depending on the events that happen around them. Sad events such as sickness or the death of a loved one produce a sad mood. Happy events, such as attending a wedding, induce a happy mood. These changes in emotional state or mood enrich the experience and enjoyment of life and are normally under the control of the individual experiencing them. However, sometimes individuals lose control of these changes in their emotions (see Figure 12.1).
There are three ways in which such loss of control happens:
Depression is a serious illness. When a person is depressed, the person has feelings of sadness that are excessive for the situation that has brought them on or the sadness lasts for an unusually long time. These feelings are so severe that they interfere with daily life.
Depression is important because it affects many people and causes a high level of distress. It impairs a person’s ability to deal with day-to-day problems or to carry out their responsibilities. People with depression have increased risk of death from suicide and from other physical conditions. Depression is also important because it is often under-recognised but can be treated.
About 15% of people in the world will have an episode of severe depression at some point in their lives. Women are more likely to develop depression although this has not been confirmed in Ethiopia.
Depression can affect people of all standing (Figure 12.2) and of any age, including children. A depressed person often loses interest in things that they used to enjoy or like. Depression can cause a wide variety of physical, psychological (mental) and social symptoms (summarised in Table 12.1).
|Psychological symptoms||Biological/physical symptoms||Social symptoms|
Continuous low mood or sadness
Feelings of hopelessness and helplessness
Feelings of guilt
Feeling irritable and intolerant of others
Lack of motivation and little interest in things
Difficulty making decisions
Lack of enjoyment
Suicidal thoughts or thoughts of harming someone else
Feeling anxious or worried
Reduced sex drive
Slowed movement or speech
Change in appetite or weight (usually decreased, but sometimes increased)
Unexplained aches and pains
Lack of energy or lack of interest in sex
Changes to the menstrual cycle
Disturbed sleep patterns (for example, problems going to sleep or waking in the early hours of the morning)
Not performing well at work
Taking part in fewer social activities and avoiding contact with friends
Reduced hobbies and interests
Difficulties in home and family life
For a variety of reasons it may sometimes be difficult to assess a person with depression. The person may not know that they are depressed and may therefore be unlikely to tell you about their low mood. Instead they will often complain about physical symptoms, such as headache and back pain. They may not feel like talking and you may feel pushed away by them. Some patients with depression are easily annoyed or irritable and you may find it difficult to talk to them. Finally, they may be feeling that nothing is going to help them and may think it is pointless to talk about their problems.
These are only examples of the potential barriers for assessing depression. Whenever you suspect that someone might have depression, ask directly about their mood. A person is very unlikely to be upset if you ask them directly if they have been feeling low or depressed.
We have been talking about some of the symptoms a person with depression may have. In Study Session 10 you have learned about how to ask someone general screening questions about their mental health. Now can you stop and think what questions you would ask a person who may have depression?
When you see a person who you think may have depression, just talk to the person in a natural way, listening to their problems and difficulties. This will give you the opportunity to understand the kinds of problems the person may be having as well as to explore their emotions. The questions you ask and the emphasis are likely to vary from person to person, but there are general and specific questions that you can use to screen for depression. Some simple questions that you can use are:
There are many different factors that can trigger depression. These causes are generally divided into three broad groups – biological/physical, psychological and social, described in more detail in Study Session 9.
Biological or physical: Chemical changes in the brain may contribute to the onset of depression. For example, a person’s mood can change with hormone levels going up and down. This is sometimes seen in women when depression may occur with the menstrual cycle, childbirth and the menopause. Depression can also follow other known diseases such as goitre (caused by deficiency of iodine in the diet) or low thyroid hormone level, anaemia and some infections. Drinking excess alcohol or some prescribed medications, for example, anti-hypertensive drugs (drugs taken to reduce high blood pressure), can occasionally cause depression.
Psychological: For some people, upsetting events, such as bereavement, divorce, illness and job or money worries can be associated with depression.
Social: Poverty, lack of adequate support and doing fewer activities or having fewer interests can lead to depression. Withdrawal from social contact may happen because of depression and this can lead to a cycle of worsening of depression.
Family history may also play a part. When there is a history of depression in parents or siblings (brothers and sisters), there is a slightly increased risk of developing depression. On the other hand, many people who have a family history of depression never develop the condition.
You should note that depression does not always have an obvious cause. Moreover, there is rarely one single cause of depression — usually, different causes combine to trigger the condition. For example, you may feel low after an illness and then experience a stressful life event, such as bereavement.
Grief and depression share similar characteristics; however, there are important differences between the two. Grief is a natural response to a loss and depression is an illness. But it can sometimes be hard to distinguish between the two. An important distinction is that people who are grieving are still able to enjoy things and can look forward to the future. But those with depression tend to have constant feelings of sadness and have little enjoyment or positive expectations of the future.
The first two months after childbirth (see Figure 12.3) are associated with increased risk of depression. The most common condition is called postnatal blues, which is a mild and transient depression occurring in the first five days after the child is born in about 50% of mothers. The mother feels easily upset, tearful and less confident about herself and her role. Support and reassurance from husband and family is sufficient. Some simple traditional practices that give a sense of security, such as keeping a metallic item under the pillow, and practices indicative of support from husband and family, are also important. But the blues can progress into more severe depression.
What do you think are the similarities and differences in symptoms of postnatal depression and depression occurring at any other time?
If you thought that the symptoms are generally similar, you would be correct. The reason why postnatal depression has a separate name is because depression is common in this period.
Additionally, in postnatal depression, mothers tend to worry a lot about their child and their ability to look after the child. They also worry about their appearance and whether their husband has the same affection towards them. The treatment is similar to ordinary depression. But note that the child could be at risk of harm from either violence or neglect by the mother (see Section 10.4 of Study Session 10). Therefore, enhancing support and managing potential risk are important.
You will find that many of the individuals you find with depression in your community will have a mild illness and their depression will improve with some support from you, their family and friends. There is only a small group of people who will develop severe depression. Before discussing what exactly you can do to help both the individuals with mild and more serious depression, let’s talk about the key principles that will form the basis for your actions (Box 12.1).
Determining the severity of depression will allow you to decide whether you need to refer the individual with depression to the next health facility for further assessment. The severity of depression depends on the following:
Based on the above criteria, you can classify depression into three types: mild depression, moderate depression and severe depression (see Box 12.2).
Treatment of depression usually involves a combination of self-help, drugs and specialised treatments. Specialised treatment refers to treatment provided by specialist mental health services. But most depression does not require specialised treatment and there is a lot that you can do at the community level.
In most cases of mild depression you need to just regularly monitor how the person is doing. You need to monitor the person for any worsening of symptoms, and for improvement in the problems that may have led to the development of the mild depression. You especially need to check for deterioration in the level of self-care and for any indications of risk of self-harm or harm towards others. Tell the person that if they feel worse, they should let you know. In Section 12.9.2 we will discuss some practical advice you may give to people with depression.
When mild depression becomes a persistent problem (a depression lasting for two years or longer), you should refer the person to the next higher level of the health system. If the illness becomes more severe or you identify risk of self-harm or harm to others, you should also refer the person. Another reason for referring someone with mild depression is when you suspect their depression may be related to a physical illness such as diabetes, hypertension or other life-threatening condition.
Individuals with moderate or severe depression require evaluation at a higher health facility, so you should refer them. Between visits to the higher health facility you should continue to monitor the patients in your community, similarly to what you would do with someone with mild depression.
There are effective medications available to treat depression. You will not be prescribing any medication but people from your community who take medication may want to discuss this topic with you. We will therefore be telling you a little bit about this here. In Ethiopia, the four main drugs currently available for treating depression are called:
Although all these medications are safe, amitriptyline and imipramine can be dangerous if a patient takes too many of these tablets. The person will not improve from their illness by taking too many tablets but their heart could be seriously affected and they could die as a result.
Please note that some individuals may wish to take part in traditional healing practices, for example wearing amulets, attending for prayers and holy water, etc. Some individuals may even benefit from these traditional interventions. The important thing to remember here is that, if someone has benefited from these practices, there is no need to discourage them. However, it is important to encourage patients to continue taking their medication while taking part in these traditional practices.
Depression is mostly a self-limiting condition. A condition is called self-limiting when it goes away without specific medical intervention. This is the case for about half of the cases of depression. However, the other 50% of individuals who have their first episode of depression will go on to have a second episode. And most of these individuals (about 85% of them) are likely to have more episodes.
Unfortunately, the main complication of depression is death from suicide. Up to 15% of individuals with severe depression (about 1 in 7) will die from suicide unless they are properly treated and followed up. Additionally, those with depression are more likely to develop other medical problems such as hypertension, other heart conditions, diabetes mellitus or infectious conditions.
There are four issues you need to raise with your patient:
Each of these points will be discussed in more detail in the sections below.
This discussion with your patient partly depends on what you have learned from the story of the person. Reflect this back. For example, if there has been an ongoing difficulty (e.g. job problems) or a loss event (e.g. death in the family), you can say that these things may have contributed. You can then tell them that these difficulties do trigger changes in the brain that can lead to depression. But let them also know that depression is common and that we don’t always know why people become depressed. Some people associate depression with personal weakness. In that case it is important to explain that the condition has nothing to do with personal weakness and that they should not blame themselves for becoming depressed.
When you visit a person with depression, allow them to speak to you about their problems and discuss how they can solve these problems. Rather than you telling them what they should and should not do, allow them to come up with solutions to their problems that they think would work. Not all problems can be solved. When there are problems that cannot be solved, encourage the person to try to accept this. Some practical points of advice you can give to people with depression include: encourage the person to eat regularly; to continue doing the things that they enjoyed before they became depressed; to be active; to mix with people and to visit their friends and relatives as much as they can.
People with depression and their families may feel more comfortable and reassured when they receive information about what will happen after referral. It is best if the person is referred to a familiar place. They will feel less confused; it will be easy for the family to travel with them and for them to get additional support should they need to. However, it is sometimes unavoidable for the person to be referred to a distant place, like Amanuel hospital in Addis Ababa. Explain to the person that because they are being referred for depression it does not mean they will be treated differently. Tell them that they will get an opportunity to discuss their difficulties further and that if required they will get additional laboratory investigations. If the doctor confirms the diagnosis of depression, they may get some counselling and come back with or without treatment. If someone has severe depression, for example, if they are suicidal, they may have to stay in hospital for a brief period of treatment. If they are prescribed medication they can continue it from home; reassure them that you will be prepared to support them.
Some people with depression may not think they have an illness; in that case you should explain to them that depression is an illness. Others may ask you about medication, so you can give them the information provided in Section 12.6. Please remember that you are not likely to know all the answers to the questions a patient with depression and their family and friends may have. You should not feel you should and this study session is not intended to prepare you to have the answers to all the questions. When you don’t know the answer to a question, tell them politely that you don’t have the training to know the answer to that particular question. But you may be able to judge whether the question is an important one that should be answered. If you are unsure about a particular issue raised by a person with depression, or a family member, you may need to consult another professional colleague. When you think the question is less important, you can reassure the person.
You have now come to the end of the session on depression. To finish let’s summarise the most important issues you have learned.
In Study Session 12, you have learned that:
Now that you have completed this study session, you can assess how well you have achieved its Learning Outcomes by answering these questions. Write your answers in your Study Diary and discuss them with your Tutor at the next Study Support Meeting. You can check your answers with the Notes on the Self-Assessment Questions at the end of this Module.
Read Case Study 12.1 carefully and then answer the SAQs below.
Mrs Woynitu is a 35-year-old married woman living in one of the villages you are responsible for. She seems to have changed in her behaviour of late and appears irritable and non-caring whenever you visit her house. She does not seem interested in talking much. You have been wondering whether she has some problems with you personally. However, in one of your regular visits, she tells you that she often has headaches and back pain and has not been able to carry out her household work because she has been feeling more tired than usual.
When you talk to Mrs Woynitu further, she tells you that she has been feeling this way for about three months now. Three months ago she had a major conflict with her husband, who would have assaulted her had it not been for the intervention of neighbours. Her relationship with her husband has been bad since that time. She had struggled to get the work done because of her tiredness and lack of concentration on activities. She does not like it when neighbours visit and talk. She has also lost her enjoyment in coffee. She has lost her appetite and has lost weight. She thinks that her son’s school problems are her fault although she is unable to say what exactly she has done wrong. She sometimes thinks bad things may happen to her and her family. She even sometimes thinks life is not worth living and wishes she were dead.
Which of the key symptoms of depression are present in Mrs Woynitu’s story, suggesting that she has depression?
Mrs Woynitu has several symptoms of depression. You have noticed that she has become more irritable, which some individuals manifest instead of feelings of sadness. She has also lost energy and concentration. She seems to have lost interest and has begun blaming herself. She has lost appetite and weight. She is also feeling hopeless and is having death wishes. All these symptoms of depression are also mentioned in Table 12.1. Not only does she have numerous symptoms but she also has problems with her functioning in that she struggles to do her daily work and her relationship with her neighbours seems to have deteriorated. As this case illustrates, depression is not only about behavioural symptoms, but also about impairment in daily functioning.
Why do you think it may be difficult to assess Mrs Woynitu and to consider depression as a possibility?
It is not very difficult to identify symptoms of depression in Mrs Woynitu. However, there are at least three barriers that may impede your ability to recognise depression:
Why do you think Mrs Woynitu may have developed depression?
Mrs Woynitu’s marital difficulties may have triggered her depression. But her self-blame and disinterest in engaging with the neighbours may lead to worsening of her depressive symptoms. Although you could think that the depressive symptoms are understandable consequences of the marital conflict and not real depression, it is not common for people to have so many depressive symptoms just because of difficulties in their lives. Mrs Woynitu also has symptoms that are difficult to explain in terms of these difficulties. For example, feeling too hopeless to the extent of having death wishes, self-blame and lack of enjoyment are not usual in people feeling depressed because of some difficulties in their lives.
Describe how you may help Mrs Woynitu.
Would you refer Mrs Woynitu to a higher level health facility? If yes, why, and if no, why not?
Overall, there are many reasons to support referring Mrs Woynitu. She appears to have a severe depression given the number of symptoms she has, the potential risk and functional impairment. When someone has severe depression it is better to refer them. Mrs Woynitu is likely to require medication and will need this prescribed from the nearby health centre or hospital.