By Consultant Psychiatrist Dr Sameer Sarkar
If you are reading this, you are likely to be experiencing some symptoms commonly associated with depression, or know someone who is. You could be the parent of a teenager, a young adult, spouse, employer, colleague or just a friend. You have concerns about some of the behavior someone is exhibiting. Or you could be worried about how you are feeling lately and the impact it is having on you and those around you. You think something is not right, yet you do not know what to do. After all, you could not be mentally ill, or crazy, can you?
The first NICE (National Institute of Clinical Excellence) guidance was issued way back in December 2004. It did mention the symptoms one presents with, and the treatment options, both in Primary (GP) and Secondary (Community Psychiatric Services). It simply asked doctors to look out for symptoms, even if they are not the main problem the patient presented with. GPs were asked to look for were what I call ‘Barn-Door’ symptoms, such as low mood, suicidal thoughts, sleep and appetite loss, tiredness, low energy and lack of pleasure or interest in ordinary things.
The clever people at NICE had another look about 5 years later and noticed that things have changed. People were coming to their GP with what is called ‘sub-threshold’ depression (meaning not with the ‘Barn Door’ symptoms) and presented with experiences of more subtle nature, such as sleep problems alone, or slowing down (both in body and mind), poor concentration, appetite or weight change (without dieting), or general feeling of worthlessness, self-recrimination and such. Curiously, people did not present with purely sexual symptoms such as loss of libido (both males and females) then, and they do not now!
So, the nice guys at NICE came up with a suggestion to look for these subtler symptoms and issued guidance on what should be done when patients present with these symptoms, whose presence (solely or in combination with another one or two) would not have cut it as ‘Depression’ before (as per the DSM (American) or ICD) text). To diagnose depression, these manuals need at least 5 symptoms, present for much of and over 2 weeks. The books still require that (do not ask me why) but NICE in its infinite wisdom has asked to identify those who do not have the ‘Barn Door’ symptoms but has couple of the so called subtler symptoms. They call them ‘Sub-Threshold Depression’ and say that identifying these, and initiating treatment promptly (not necessarily with antidepressants) is the way to go.
It is recorded that 1 in 4 (or 25%) of us have experienced some kind of mental health problems in our lifetime. That is a frighteningly high percentage. Bear this number in mind the next time you see someone struggling and you think that they ‘should just pull their socks up’ or are ‘weak’. In fact, a good amount of time I spend in the initial consultation with someone presenting with depression is to tell them how brave it is to come and seek professional help in the first place. It does take a lot of courage to come to a doctor and admit that we are struggling, even if you are forced or frog-marched to the doctor’s office by someone concerned about it. The double whammy of ‘stigma’ of mental illness and ‘denial’ that anything could possibly be wrong and needs fixing (likely to be derived from the stigma, or in some cases, pride, or plain foolishness) is one of the toughest barriers one faces to deliver high level care to the patients.
But hey, at least now we have ‘celebrities’ such as Raheem Sterling (not sure he is still a celeb after EURO2016!) ‘coming out’ admitting his mental struggle. Surely the fight to beat stigma is almost over, right? Wrong. ‘Celebrities’ have long been ‘coming out’ with their struggle with depression, bipolar, drug addiction, alcoholism before a certain Manchester City footballer did so, but it has done precious little to raise awareness or remove the stigma of mental illness. As an aside, I do hope that Raheem Sterling’s abjectly pathetic performance at the EURO 2016 does not make people think that ‘he should not have been taken if he was a cuckoo’ and indirectly increase the discrimination against the mentally ill. Not that the other 22 covered themselves in glory by their equally pathetic performance either. But I digress.
The point is, depression or mood disorder does not always present with ‘Barn Door’ symptoms. When it does, it is easy to see. Hence the term ‘Barn Door’. More often it presents with soft symptoms, either discreet or just couple of soft symptoms. Hence NICE suggests that assessment should not be based on ‘symptom count’. The whole picture is to be assessed, so inquiry must be made of the ‘soft’ symptoms, and more importantly the functional impairment arising from them. If a person is staying up all night, and consequently too tired next day to do her job, or regularly being late at work, or simply being unmindful which leads to her co-workers thinking ‘something is not right with her’, she is probably not right even if she does not feel low in mood, and still manages to attend the obligatory ‘girl’s night out’.
She is likely showing symptoms of the so called ‘sub-threshold depression’ even though she based on the DSM-IV, the definition of depression thus is:
Subthreshold depressive symptoms: Fewer than 5 symptoms of depression (see at the end where I list them).
Mild depression: Few, if any, symptoms in excess of the 5 required to make the diagnosis, and symptoms result in only minor functional impairment.
Moderate depression: Symptoms or functional impairment are between ‘mild’ and ‘severe’.
Severe depression: Most symptoms, and the symptoms markedly interfere with functioning. Can occur with or without psychotic symptoms.
Why am I telling you all of this? I am telling you this because, I and many clever psychiatrists like myself knew, much before NICE said it, that mood symptoms can present as symptoms other than mood. We knew it and we failed to pass this knowledge along to those in the frontline. We knew that sometimes presentation with other symptoms such as forgetfulness, lack of concentration and paying attention to details, low sexual drive, or simply ‘unexplained’ weight change, severe and persistent tiredness or fatigue does not mean that the patient necessarily has Dementia, ADHD, Erectile Dysfunction or Thyroid problems. We knew that these serious maladies could be present but more likely those are the symptoms of depression even though the ‘symptom count’ does not reach the threshold.
We knew, but we did not do much about it. We continued to look away hoping the others will pick these people up, and send them our way. While this was going on, we were busy inventing new areas where we could intervene. Such as ‘Sex offender’ treatment, public safety, Guantanamo Bay, or the unfairness of the ‘cuts’. At last, a bunch of Technocrats from NICE (rather few of them doctors, and only two of them GPs) told us it is so. This is our mea culpa maximus.
The Typical Patient
So what symptoms (what patients experience) should alert you or your close ones that all is not right? I hardly wish to scare you but almost anything you feel or experience that is ‘not you’ can be an early sign. At that point, it is not causing much problems so you will be justified to think it as trivial but time passes, a new symptom presents, and you become a little more unsure of yourself. You still do not think it is a problem, that it is a temporary ‘thing’, a ‘phase’ or a ‘reaction’ to something, or simply ‘stress’. But annoyingly, you realise that you just cannot shake it off. And you worry. Until one day, you break down in tears when your manager pulls you up for sloppy work. Or you suddenly feel that jumping in front of a moving bus is a perfectly good end to your misery. When you are finally stopped from jumping off a building, or forced to ‘go home’ at work, or the paramedics take you to the nearest emergency room, you finally figure out that something was not right for a long time.
The not-so-typical Symptoms
Take for example, lack of concentration or inability to concentrate on work at hand. Students notice this, but sadly only when it is time for exams or handing over coursework. If this is a new development (you did not struggle in the past and no one ever accused you of being scatty before) the chances are you may have an underlying mood disorder. The mind of the depressed patient is all over the place. It is an unquiet mind. You may not realise it but there are things going on in your head, sometimes at speed of light (so to speak). How could you possibly pay attention to the mundane things around you or concentrate on boring stuff. What you do not do, and I invite, (no, I implore, I insist) you to think: ‘hmmmm..this is strange, never had this before..wonder what’s going on..better go see someone’.
Or consider the more common presentation among today’s health conscious, body-image driven people. Losing weight (without trying) may be an ‘early Christmas present’ but is it because you do not feel like eating? Or have no interest in food, or your appearance? Are people noticing the dark circles around your eyes (I suspect these circles are more metaphorical than real for I have never seen them myself on anyone except Pandas and Raccoons) and wondering ‘what diet is she on?’ Or have you noticed that your clothes are getting tighter, you are feeling ‘chunkier’, and it has been long since you stepped on the bathroom scales. Weight change usually is accompanied by appetite and it is not common to notice a subtle increase or decrease in appetite, or enjoyment of food. You start thinking of this as the new ‘normal’ for you. Until someone, rather tactlessly, point out that ‘you have grown’. Or worse still, ‘are you pregnant’?
How about sleep or lack of it? Yesterday there was a hashtag trending on Twitter called #IAmAwakeBecause. Now I concede that the seriously depressed are unlikely to be on Twitter anyway, especially at wee-hours, but I read through at least a thousand of those tweets and found that ‘it just is’ to be the commonest response. Of course some suggested they were partying, some were tending to babies who woke up in the middle of the night, but ‘that’s how it has been for a while’ was the frighteningly common response. Few of the responses said ‘I can’t sleep’ and ‘damn now I am going to be tired all day’. Nobody shared how they feel but I guess on Social media you are not supposed to describe ‘negative’ emotions. Only anger, hurt due to ‘micro-aggression’ and how great you are.
‘No Sex Please, We Are British’
People used to say this jokingly, but now it is more like ‘No talk about sex please, because it is rude’. While there are no shortage of drunken braggadocios who talk about their most recent conquest, real or imagined, by and large people do not talk about their sex-life even with friends. Lack of interest, or pleasure from sex can often be the only symptom noted, but only on sensitive questioning by an engaged clinician. The accompanying symptoms, such as tiredness, anxiety accompanying the loss of interest or pleasure from sex (in both sexes) are less frequently recognized.
Alcohol, The Greatest Medicine
Of course, anxiety accompanies depression like drunken behaviour accompanies a night of binge drinking. Almost always present, but almost never recognised. ‘I was drunk?’ is the common incredulous response when one is reminded of last night’s shenanigans. If anxiety accompanies depression, it is always necessary to treat the depression first. Most of times, the anxiety will disappear. But sometimes overwhelming anxiety, anxiety of physical kind, like sudden hot flushes, feeling of emptiness in chest, lightheadedness, or sudden goosebumps or dizziness or an episode of heart pounding in chest without visible or probable cause may be the only presenting symptom of depression. If the anxiety has become ‘somatic’ as in bodily [sensations], the depression is potentially quite serious. More common is the generalised free flowing anxiety, ‘just the feeling something is going on’ without being able to what it is, or panic attack which brings one to a doctor. After all, ‘feeling’ something in your ‘body’ is more the reason to see a doctor than ‘not feeling’ or feelings in your heart/mind. Right?
Many a time, and more often than we would like, the sole presentation may be increased use of alcohol, and/or drugs. Alcohol is a known depressant, as in if you feed it in sufficient quantity to someone not depressed, he is guaranteed to become depressed. It is also an aesthetic, kind of. As in it numbs the pain, the emotional upheavals and the torment. It is the ‘local aesthetic’ for the soul. That it does, but it also does the opposite. It is a cruel paradox that depressed patients, or depressed patients with significant anxiety, turn to alcohol precisely because they are experiencing the pain, the torment. Seldom do they realise that the alcohol is making the depression worse. Seldom do they care. But it does present an unwelcome challenge to the clinician.
The Chicken or the Egg?
A thoughtful clinician certainly would be able to figure it out after a careful history taking but for the patient, it is the ‘chicken and egg’ situation. Drugs work in similar ways although drugs are more likely to push people deeper into the throes of depression and more severely than alcohol does. Or it can make them psychotic. Either way, it is not a good feeling. Best to stay away from them. Or use it in moderation.
Because to say so perhaps is openly ‘sexist’, no one has ever said it. But there is a definite difference between what I call ‘Male Depression’ and ‘Female Depression’. The accusation of ‘sexism’ may not be totally untrue for the divide is based on stereotypes. So with apologies in advance to those I offend, let me tell you what I mean. Men, for reasons unknown (because researching it would be so ‘sexist’), are less likely to experience ‘low mood’ or acknowledge them. Seldom will you see a man with slouched soldiers, sad expression and being slow in thinking or activities.
You will, but not as commonly as the ‘angry’ man. You will not notice him to be moping around in sadness or self-pity, but see him being perma-angry, angry at everything, everyone, especially those in his orbit. You will notice that he is seemingly unable to control the furious anger that is consuming him. He will snap at everyone, swear obscenities, and be angry at himself. The irritability is kind of a defence against feeling low; the expression of anger a defence against the inadequacy (or low self-worth) he feels. Of course because it is common for men to have public displays of anger, often way beyond any sense of proportion, I wonder if this very sociological phenomenon has become a symptom. Often the anger is fueled by a deep seated ‘paranoia’, not in the sense of some delusional or psychotic thoughts, but a free-flowing paranoia with which he has tarred the world so where everyone is out to get him/annoy him. Deep down he believes that he deserves to be treated badly because that is what he deserves.
Female depression on the other hand may follow the text book, or they can be modified by a remarkable lack of some core symptoms. A ‘stay-home mom’ will valiantly perform every task she is required to complete, even though she will not do them as well. The children have to be fed, watered, taxied to school. The house needs straightening out. The clothes do not wash themselves and takeout after takeout is bound to raise suspicion. So they soldier on, bravely if somewhat foolishly, unnoticed and uncared for to the point of total exhaustion or till she flops with ‘can’t do this anymore’. By this time, she may be suicidal, or at least questioning the futility of it all and her own existence.
No one has noticed that she has not been eating, drinking a bit much, falls asleep at odd times, or looks always tired and down. Because that’s what moms do. Yes, there could be the occasional snapping at people, or the harsh talk, or the house is becoming a bit messy. But the anger is nothing like her male counterpart. Similarly, the man could also be soldiering on with his work, because someone has to ‘bring home the bacon’. These overlaps of gender dependent symptoms are more of a sociologic difference in perception of gender roles than actual empirically proven difference in symptomatology. It is, at best, distinction without difference.
The Cognitive Triad
Differences aside, depression is depression. It diminishes you, it grinds you down and you start to not believe that you are the same person you were. The ‘cognitive triad’ of depression says it all:
- Negative view of self or I am rubbish (at everything)
- Negative view of others or everyone hates me
- Negative view of the World or everything sucks
It is as if you have been forced to wear dark glasses and are prohibited from taking it off. And everywhere you look, it is dark and bleak. No matter how much you blink, or shake your head, the darkness does not go. It is everywhere. William Styron, the great American author (decidedly not a fan of psychiatry when he was suffering from depression), tells it in a heart-wrenching memoir ‘Darkness Visible’ (insert Link to Amazon). It is not easy reading, but it is something everyone who suffered from depression will relate to.
Go See Someone
That someone need not be a doctor, or even a psychiatrist. Often it is sufficient to just see a counsellor, or therapist. Remember the nice guys at NICE? They say, Low-intensity psychosocial interventions are usually adequate, and to offer for mild or sub-threshold depression:
one or more of the following interventions, guided by the person’s preference:
- individual guided self-help based on the principles of cognitive behavioral therapy (CBT)
- computerized cognitive behavioral therapy (CCBT)
- a structured group physical activity program.
Starting treatment: What to Expect
The First Visit:
The first visit involves a careful history taking, perhaps even getting some corroborative evidence from people who know you and establishing a diagnosis. If it is moderate depression, we offer antidepressant medication to all patients routinely, before psychological interventions.
I never tell you that ‘thou shalt take this’ potion. I will insist that you be an equal partner in choosing what medication to use. The stuff you are not expected to know I am there to tell you. The stuff you know, like how your body works, allergies, past medication or any current medication you are already taking, you will tell me. We will always discuss your fears of addiction or other concerns about medication. For example, I shall explain that craving and tolerance do not occur.
When starting treatment, I will tell you about:
– the risk of discontinuation/withdrawal symptoms
– potential side effects.
Finally, I shall always tell you about the delay in onset of effect, the time course of treatment and the need to take medication as prescribed. If you want, I can even give you or direct to available written information appropriate to your particular needs.
First Follow up session
The first follow up session is very important and almost always necessary to monitor side effects and tolerance along with any deterioration of mood symptoms.
I ask to see patients who are considered to be at increased risk of suicide or who are younger than 30 years old 1 week after starting treatment. I advise that the patient is monitored frequently until the risk is no longer significant. This could be through visits to my office, telephone, Skype session or even through local mental health services (Home Treatment Team or Crisis Team if the patient has engaged with NHS services)
In Patients who are not considered to be at increased risk of suicide the First Follow-up visit could be 2 weeks after starting treatment and regularly thereafter – for example, every 2–4 weeks in the first 3 months reducing the frequency if response is good.
For patients with a moderate or severe depressive episode, my advice is to continue antidepressants for at least 6 months after remission.
Once a patient has taken antidepressants for 6 months after remission, the doctor will review the need for continued antidepressant treatment. This review may include consideration of the number of previous episodes, presence of residual symptoms, and concurrent psychosocial difficulties.
What to Expect when treatment stops
All patients are informed about the possibility of discontinuation/withdrawal symptoms on stopping or missing doses or reducing the dose. These symptoms are usually mild and self-limiting but can occasionally be severe, particularly if the drug is stopped abruptly.
We advise patients to take their drugs as prescribed, particularly drugs with a shorter half-life (such as Paroxetine and venlafaxine).
Once decision is made to stop the medicine, it is done slowly. I usually reduce doses gradually over a 4-week period; some people may require longer periods, and fluoxetine can usually be stopped over a shorter period.
For mild discontinuation/withdrawal symptoms, all that is needed is simple reassurance to the the patient and monitoring of symptoms.
For severe symptoms, I may even consider reintroducing the original antidepressant at the effective dose (or another antidepressant with a longer half-life from the same class) and reduce gradually while monitoring symptoms.
I always ask patients to seek advice from their doctor if they experience significant
CBT (Cognitive Behaviour Therapy) is the psychological treatment of choice. Alternatively, Dynamic interpersonal psychotherapy (DIT) is useful if the patient expresses a preference for it or if we think the patient may benefit from it.
Both CBT and DIT should be delivered by a healthcare professional competent in their use – treatment typically consists of 16 to 20 sessions over 6 to 9 months. We have many of these specialist therapists to choose from.
Although not ideal, CBT (or DIT) for patients with moderate or severe depression who do not take or refuse antidepressant treatment could be considered.
If the patient has responded to a course of individual CBT or DIT, follow-up sessions – typically 2 to 4 sessions over 12 months are useful to maintain remission.
Always remember, you do not have to do it alone. We are here for you. Because everybody needs help, sometimes.
Disclaimer: Lest I be accused of sexism, I wish to declare that in this piece, singular includes plural, feminine includes masculine and we is the ‘Royal We’.
Diagnostic Criteria for Depression as per DSM-IV
For at least 2 weeks, the patient has had 5 or more of the following symptoms, which are a definite change from usual functioning. Either depressed mood or decreased interest or pleasure must be one of the five:
Mood: For most of nearly every day, the patient reports depressed mood or appears depressed to others.
Interests: For most of nearly every day, interest or pleasure is markedly decreased in nearly all activities (noted by the patient or by others).
Eating and weight. Although not dieting, there is a marked loss or gain of weight (such as five percent in one month) or appetite is markedly decreased or increased nearly every day.
Sleep. Nearly every day the patient sleeps excessively or not enough.
Motor activity. Nearly every day others can see that the patient’s activity is agitated or retarded.
Fatigue. Nearly every day there is fatigue or loss of energy.
Self-worth. Nearly every day the patient feels worthless or inappropriately guilty. These feelings are not just about being sick; they may be delusional.
Concentration. Noted by the patient or by others, nearly every day the patient is indecisive or has trouble thinking or concentrating.
Death. The patient has had repeated thoughts about death (other than the fear of dying), suicide (with or without a plan) or has made a suicide attempt
Link to: Anxiety Disorder
People with Generalised anxiety disorder (GAD) go through the day filled with exaggerated worry and tension, even though there is little or nothing to provoke it.
GAD is diagnosed when a person worries excessively about a variety of everyday problems for at least 6 months. They usually realise that their anxiety is more intense than the situation warrants.
They can’t relax, startle easily, and have difficulty concentrating.
Often they have trouble falling asleep or staying asleep.
Physical symptoms that often accompany the anxiety include fatigue, headaches, muscle tension, muscle aches, difficulty swallowing, trembling, twitching, irritability, sweating, nausea, lightheadedness, having to go to the bathroom frequently, feeling out of breath, and hot flashes.