When is depression not depression?

Fiona Clark

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Fiona Clark

Journalist

Fiona Clark

 

When is depression not depression? Ahead of his upcoming lecture at Healthed’s Medical Update in September, Psychiatrist and University of Melbourne Clinical Associate Professor David Horgan gives some insights.

Some decades ago the World Health Organisation (WHO) predicted that depression would be the leading cause of disease burden globally by 2030. Associate Professor thinks we may have hit that mark early.

“The pressure on people now is dramatically higher than it was 20-30 years ago. Expectations and pressures are higher, and that’s why we crumble. That’s why depression is extremely common.”

There are other factors too, he says, that may be contributing to the rise in depression cases. One is that the stigma surrounding depression has been greatly reduced over recent decades and another is because we know that antidepressants work, so more people are coming forward and seeking treatment.

But, various questions remain including when is it clinical depression, when is the right time to intervene with medications, and when are the symptoms indicating other conditions?

From Associate Professor Horgan’s point of view, the first thing a GP needs to think of when confronted with a patient exhibiting symptoms of depression is whether there are other underlying physical conditions that could be contributing factors, such as anaemia, sleep apnoea or an underactive thyroid.

Other things to consider include whether there’s a substance abuse issue such as excessive alcohol consumption, smoking cannabis heavily, or opioids.

Then there are personal circumstances to take into account, such as bereavement or difficulties with relationships.

“Anybody, male or female, with relationships problems will be distressed and that may trigger off depression as an illness,” Associate Professor Horgan says. But sometimes these may resolve without the need for pharmaceutical interventions, he says. While antidepressants are effective, he warns they come with side effects and not everyone may need them.

Determining who does and when are key. He says he gives his patients scales of 0-10 to subjectively rate the severity of their symptoms.

“I ask them to rate ‘how bad are your stressors, how bad is your anxiety, how bad is your depression, how bad is your emotional pain? I also ask ‘do you wish you didn’t wake up in the morning?’, ‘have you thought of doing something about that?’, and ‘have you been taking risks?’”

Fleeting thoughts of not being alive, he says, are part of being human, but when they start to become “strongly tempting, to feel logical because the pain will never be cured, then that’s an issue.”

An inability to concentrate, especially being unable to remember what you’ve just read, indicates it may be time to intervene.

Associate Professor Horgan says many people recover from depression and medications need to be tritiated to suit the level of symptoms. As depression subsides, over-medication relative to symptoms may mimic depression relapse.

He has a simple mnemonic to help here: “YES”.

The ‘Y’ is for yawning or being drowsy, the ‘E’ is for expression problems such as struggling for words and the ‘S’ is for making simple mistakes such as spelling problems or losing things, that are uncharacteristic for that person.

Associate Professor Horgan says many people with depression can still go to work in this condition, and they go through the motions, but they’re functioning well below par. He calls this ‘presenteeism’.

“They’re there in body, but not in mind,” he says.

“When they can’t remember what they’ve read, the brain chemistry is broken down, and people get by on stored memory.”

Associate Professor Horgan says depression is a “slow burner” but it goes hand in hand with anxiety, and if there are “rapid fluctuations in mood swings, from ok to terrible, that strongly suggests the anxiety needs to be treated as well as the depression.”

Sometimes, however, the symptoms can be what he describes as “suspicious depression” and he’s developed another mnemonic for this that he’ll share fully in his upcoming lecture. The ‘suspicion’ is where the symptoms may also indicate a tendency toward bipolar disorder.

He says it’s not a crystal ball, but certain presentations, such as ‘S’ – sudden onset, ‘U’- under 25 at first presentation, ‘S’- swings in mood – to start the mnemonic off, may suggest the condition “could later become bipolar.”

In these cases, he says it may be worth considering a mood stabiliser as well as the anti-depressant.

Associate Professor Horgan adds that the brain is a complex organ and does repair itself, but the downside of that neuroplasticity is that depression becomes a learned behaviour.

“The first episode is nearly always stress induced and as the brain learns from this, it can easily be triggered again.”

As a result, he says “total eradication” of the first or second presentation of depression if possible, and dealing with vulnerability factors as far as possible, are key to long term management.

For much more from Clinical Associate Professor David Horgan, register here to attend Healthed’s upcoming Medical Update in both Melbourne and Sydney in early September.

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