Treating Depression

Depressed mood or sadness lasting two weeks or more requires treatment. We all feel depressed, sad, or ‘blue’ occasionally. Moods and feelings change in response to events in our external environment. Usually depressive feelings or sadness last for a day or two; longer in case of loss or bereavement. However, if these feelings of sadness and hopelessness persist for more than 2 weeks and interfere with daily life, it indicates a clinical depression.

Depression is the fourth highest contributor to the global burden of disease. 

Clinical depression is a treatable illness. Many people never seek treatment due to lack of awareness, lack of access to mental health care, ignorance, or shame.

Signs and Symptoms

The hallmark of Clinical Depression is a pervasive depressed mood. This depressed mood is not responsive to positive events. There is associated slowness of thinking and movement; and there are thoughts related to guilt, self-blame, hopelessness and suicide . These features of constitute the classical triad of symptoms for the diagnosis of Clinical Depression. For a more formal diagnosis some or all of the symptoms below are used

1. Persistent sadness. Frequent crying, irritability, ‘emotional outbursts’
2. Slowing of movement and thoughts
3. Feelings of guilt - ‘I shouldn’t have done that’, ‘it is all my fault’
4. Worthlessness - ‘I haven’t achieved anything’, ‘I let my parents down’, ‘what I do has no value’
5. Hopelessness - ‘What’s the point?’, ‘I don’t see things getting better’
6. Thoughts of dying and suicide - ‘I would be better off dead’
7. Loss of interest in activities and hobbies that were once pleasurable
8. Difficulty concentrating, remembering details, making decisions
9. Insomnia, early morning wakefulness, excessive sleeping.
10. Change in appetite – appetite loss or overeating.
11. Fatigue, lethargy, decreased energy
12. Headache, cramps or digestive problems that are not relieved by treatment

How is depression treated?

The first step to treatment is to visit a psychiatrist. Your psychiatrist is the only mental health professional qualified to prescribe medication and provide psychotherapy. Your psychiatrist will take a detailed history of your symptoms, and will ask you to complete some questionnaires to assess their severity. He will also do a physical examination and may get some tests done (thyroid disorders and blood glucose related problems can cause similar symptoms).

The treatment of depression rests on two pillars

1. Pharmacotherapy (medication)
2. Psychotherapy (counselling, CBT)

Medication (pharmacotherapy) is required for moderate and severe depressions. Formal psychotherapy is started later once concentration and thinking improve. Your psychiatrist will prescribe an appropriate antidepressant. Antidepressants are not addicting. Side effects if any occur during the initial phase of treatment, they should not make you feel worse. Antidepressants must be taken for 4-6 weeks before they have a full effect. Later you should continue the medication even if you are feeling better to prevent a relapse. Suddenly stopping antidepressants can precipitate a relapse. Medication should be tapered gradually under your doctor’s supervision. If you follow your doctor's advice regarding follow up visits your treatment will be optimal.

Psychotherapy alone may be used in mild depression. Usually it is combined with medication for moderate and severe depressions. Psychotherapy is of two types:

1. Cognitive Behaviour Therapy (CBT) identifies self-defeating, ‘negative thoughts’ and behaviours that perpetuate clinical depression in a vicious cycle. Your therapist then works with you to replace these thoughts and behaviours with ‘positive’ ones to help you recover from the illness.
2. Interpersonal Therapy (IPT) helps people understand and work through troubled relationships that may be at the root of depression or making it worse.

How can I help a friend or family member who is depressed?

1. Listen carefully.
2. Offer support, understanding and encouragement.
3. Never dismiss feelings, but point out realities and offer hope.
4. Encourage them to go out for walks, outings and other simple activities. Don’t push too hard but keep trying.
5. Make sure they keep appointments with the psychiatrist and stay in therapy.
6. Never ignore suicide comments
• Gently correct blatantly ‘negative’ thoughts. Help the person form an action plan to resolve the problem
• DON'T LEAVE THEM ALONE until they OK the plan. 
• Accompany them to a known responsible person or a doctor or mental health professional. You could save a life.

What can I do when I am depressed?

1. Stay active. Exercise; go out for a movie, or any event you previously enjoyed.
2. Eat regular meals. Don’t skip them even if you are not hungry.
3. Go to bed at a regular time. Don’t wait until you are extremely tired so you can get sleep. Insomnia is the first symptom to respond to antidepressant medication
4. Set realistic goals for yourself.
5. Break up large tasks into smaller ones and do what you can.
6. Spend time with others, confide in a trusted friend or relative.
7. Postpone important decisions such as getting married/divorced, changing jobs until you are feeling better.
8. Do not wait too long to get treatment.
9. Expect your mood to improve gradually. Sleep and appetite will improve before your mood changes.
10. Keep your appointments with your psychiatrist and do not stop your medication suddenly.

Reference

Rejection and aggression - the fury of the scorned male

Rejection experienced in an intimate relationship can trigger unexpected aggression with sometimes fatal consequences. A working woman in Pune was stabbed to death in her home when she spurned the marriage proposal of a good friend. Another 17 year-old girl from Hadapsar was stabbed in the stomach for rebuffing the overtures of a relative. Why would a man assault a woman after professing his love to her? Many instances of aggression arise from events where an individual perceives he is not sufficiently loved or valued in the context of an intimate relationship.

People differ in their readiness to perceive and react to rejection. The desire to belong is a basic human need. Some maintain equanimity while others over-react in ways that harm their relationships and their well-being. Hostility and aggression are among the most destructive reactions to rejection. Low self-esteem, depression, jealousy, self-neglect and a breakdown of daily routine are other painful outcomes of being rejected. Social rejection is the strongest predictor of violence in adolescents (Surgeon General 2001). This association between rejection and aggression is also repeatedly shown in social experiments.

Rejection triggers behaviours internalised during interactions with parents during infancy and early childhood. Based on these interactions children form certain expectations regarding the satisfaction or rejection of their needs. When childhood needs are met sensitively and consistently the child forms secure expectations. When childhood needs are met with rejection the child forms a pattern of insecure expectations involving doubts and anxieties. These repeated early interactions determine the individuals attachment style - the communication pattern exhibited in close relationships.

Aggression is first learned during infancy as a response to separation from the mother. The purpose is to reunite with the mother and discourage future separation. Adults who are socially immature respond to separation from a loved one with shouting, crying, and throwing or smashing objects. Again the purpose is to protect the relationship. Men with a fearful or preoccupied attachment style are more likely to be jealous, violent and abusive in intimate relationships. This tendency to violence increases when the relationship is threatened. Males with a fearful attachment style are anxious about gaining their partners approval and at the same time are fearful of being rejected by them. These males are more likely to attribute negative intent to their partners. This combination of internal conflict and external blame makes men with a fearful attachment style respond to rejection with aggression (Leary 2006).

Jealousy is the precursor of aggression in many close relationships. Jealousy occurs when people believe that another person does not sufficiently value their relationship because of the presence or intrusion of a third party. Men who are abusive have higher interpersonal jealousy. Abused women and the men who abuse them report jealousy as the most common precursor to violence. Among both men and women, intimate violence is often provoked by real or imagined infidelity (Leary 2006). We have already discussed jealousy in the context of the family.

Rejection-sensitivity is a personality characteristic associated with aggression elicited by rejection in love and romance. People high in rejection sensitivity (Downey 1996)

1. Anxiously expect rejection by significant people in their lives.
2. Readily perceive intentional rejection in the ambiguous or insensitive behaviour of their new partner.
3. Over-react to rejection

Gender differences (Downey 1996) dictate that men with high rejection sensitivity manifest jealousy in the face of perceived rejection. Their consequent attempts to control their love object’s interactions with other males leads to further dissatisfaction in the relationship. When they are not successful in this they respond with rage - the common fallout of jealousy. Females react to perceived rejection with hostility and withdrawal of support. Both gender reactions lead to dissatisfaction with the partner and subsequent breakup of the relationship. If taken to an extreme, the jealousy in the rejection sensitive male can lead to fatal consequences for object of his affections.

Despite these negative experiences rejection sensitive people are repeatedly drawn to intimate relationships. The new relationship is viewed as an opportunity for acceptance. Initially they work hard to ingratiate themselves with their partner. However, the inevitable transient negativity, insensitivity, or preoccupation triggers the deeply ingrained anxieties and expectations of rejection. The person over-reacts to minor and ambiguous signals from the love object and starts the cycle of dissatisfaction in the relationship.

Rejection sensitivity is deeply ingrained in the personality. An intimate partner or a therapist can alter the expectancies and anxieties about rejection. It is possible for the rejection sensitive person to develop better conflict resolution skills. But only when there is a high degree of motivation in the rejection-sensitive person and a skilled, and nurturing partner.

References

1. Özlem Ayduk, Anett Gyurak, and Anna Luerssen. Individual differences in the rejection-aggression link in the hot sauce paradigm: The case of Rejection Sensitivity. J Exp Soc Psychol. 2008 May 1; 44(3): 775–782. doi: 10.1016/j.jesp.2007.07.004
2. Downey G, Feldman SI. Implications of rejection sensitivity for intimate relationships. J Pers Soc Psychol. 1996 Jun;70(6):1327-43.
3. Leary MR, Twenge JM, Quinlivan E. Interpersonal rejection as a determinant of anger and aggression. Pers Soc Psychol Rev. 2006;10(2):111-32.
4. Office of the Surgeon General. (2001). Youth violence: A report of the Surgeon General. U.S. Department of Health and Human Services.