Accessing treatment

When someone develops a depressive illness, it is vital that they make contact with a doctor or an appropriate mental health professional. The depressed person may be experiencing symptoms such as difficulty with concentration and memory, fatigue, lack of energy, unexplained aches or pains, and loss of interest in things that once brought them pleasure. He/she may not associate these 'depressive' feelings and these diverse symptoms as all part of one disorder called depression or depressive illness or major depression. For other people, however, the persistent low mood and sadness that they experience make it more likely that they will recognize that they are experiencing depression. A doctor or mental health professional can assess the symptoms being experienced, and, being trained to identify depression, can usually make that diagnosis. At the same time, the trained person will also be aware that other, quite different, illnesses can masquerade as depression and need to be identified in their own right. Good initial diagnosis is essential for proper treatment to be undertaken and time spent on this task is time put into ensuring that all treatment possibilities are properly considered and made available.

There are a number of methods and pathways that individuals can use to access diagnosis and treatment and the following people will be helpful for individuals and/or their family to talk to:

• A school psychologist or counselor. If the person experiencing depression is a young adult, then they may be attending high school, university or college. Many of these educational institutions will have psychologists or counselors on staff that people can talk to. These professionals can also help the individual (and/or their family) to decide if they need specialist assistance, and can help to refer them to an appropriate professional.
• The local or family doctor. Because local doctors are often the first professionals to whom people turn when they experience troubling symptoms, these doctors have a vital role to play in recognizing that the symptoms the person is experiencing may be part of depression or some other disorder. The local doctor can clarify some of these issues, offer support, assess the need for investigations or for medication, including antidepressant medication and make referrals to mental health professionals such as psychiatrists or psychologists.
• The local mental health clinic or community hospital. These are available to people if they recognize that the symptoms being experienced are possibly due to depression or some other form of emotional/psychological condition or if they notice signs and symptoms that they know from past experience indicate that depression is developing. Phone numbers for these clinics are often available in local phone books and through various help-lines.
• Mental health professionals such as psychiatrists or clinical psychologists. If the person is already seeing a mental health professional, then these professionals will be in able to accurately assess, and treat, the troubling symptoms that make-up this disorder. If the individual is not currently seeing their previous mental health professional and, if they believe that the symptoms of previously experienced depression may be returning, then they should promptly contact that person. The mental health professional will re-assess the new symptoms being experienced, and will discuss further treatment options. They will also know where to direct the person and their family for further, more specialized, assistance if this is warranted.
• Telephone help lines. The inside cover of the telephone directory will probably have several telephone numbers for local telephone help lines that specialize in mental health or welfare issues. These help lines can be very useful for talking things over and for directing individuals and their families to appropriate services.

Aspects of the treatment process

The treatment process involves a series of quite distinctive steps and issues. The first of these - obtaining a definite diagnosis, has been mentioned already. Depressive symptoms may hide a physical disorder such as thyroid dysfunction or diabetes. Depression can herald intra-cerebral disease or vitamin deficiency. The matters need to be considered initially and this is very clearly the role of the family doctor or, in some countries, another primary health practitioner. Specialist psychiatrists or clinical psychologists may have to play an important role in this as may other types of specialists. Once diagnosis has been established it is usually clear as to what pattern of treatment will be most appropriate. In determining this, a series of other steps, or considerations, must be undertaken or thought about. These include some of the following issues:

The goals of treatment
The specific goals of treatment vary from person to person, however, see below for the general treatment goals.

• Ensuring the safety of the individual.
• The alleviation of troubling symptoms such as persistent feelings of sadness, decreased ability to enjoy life, negative thoughts, fatigue, difficulties with concentration and memory and sleep problems.
• The selection of an appropriate treatment program and management plan to promote recovery. This may involve medication, supportive or interpersonal therapy and/or more intensive psychotherapy, including cognitive behavioral therapy. It may also include attention to troublesome social or family issues.
• If medication is to be used it requires adequate supervision and effective minimization of side-effects if possible.
• Attention must be paid from the beginning to assessing family and other relationships and, if necessary helping to build healthy, supportive relationships between the individual, the family members and those mental health professionals involved in treatment.
• Steps to prevent the individual from re-experiencing symptoms or recurrence of illness.
• A plan for returning individuals to their usual life and their usual daily routine or workplace.

Early intervention
Whether this is a first episode of depression or whether the sufferer has experienced depression before, it is very important to seek assistance at the earliest possible time. Ideally, help would be sought as soon as the individual notices that the symptoms being experienced are impacting on quality of life or on his/her ability to carry out the usual routine. Also, the person afflicted, their family and close friends, can all play a part in becoming aware of the individual's personal 'early warning signs', and encourage the person to seek treatment if these early warning signs appear. This is obviously not possible in a first episode of depression, but can, if taken seriously, be an important factor in ensuring that subsequent episodes are brought under treatment even before more obvious illness becomes established. Taking a 'wait and see' approach is never a good idea, as the earlier that treatment is received, the sooner mood will improve and the less disruption there will be to the person's life. Some other reasons why early intervention is important are:

• If the symptoms of depression are left untreated, depressed people can start to 'believe' the negative view of themselves and their world that depression encourages. They may start to feel very bad about themselves and very worried about their future. This can result in additional problems such as lowered self-esteem and loss of self-confidence.
• Distressing symptoms can lead a person to feel helpless, hopeless, sad, worried and pessimistic and may lead to thoughts of self-harm. Depression always needs to be taken very seriously because of the danger that the person might try to hurt himself/herself.
• Episodes of depression can put great strain on family relationships and friendships, particularly if symptoms are present over a prolonged period. The earlier that help is sought and symptoms are brought under control, the less disruption that will occur in these important relationships.
• Depressive symptoms, particularly when severe, can have a negative impact on people's ability to function at work or their studies. This can lead to a vicious cycle where depression impairs work or study performance. Performing badly at work or study can lead people to feel even worse about themselves, to lose their job or fail exams, which only confirms their low self-opinion.

Barriers to early intervention
If depression is developing, or is being experienced, it is important to receive treatment as early as possible, however, there are a number of factors that can interfere with people getting the early help that they need. Recognizing possible barriers is the first step to overcoming them. Some of the barriers to early intervention include:

• Individuals and their families may be worried about the stigma attached to seeing a mental health professional or about what it means to be experiencing a 'mental illness'.
• People may be worried that depression or the treatment of depression will interfere with their jobs or with their studies. In fact, the earlier that treatment is obtained, the less disruption that will occur to these aspects of people's lives.
• The families, co-workers or friends of the person experiencing depression may not understand the changes that are taking place in their loved one's behavior, and may believe that the person is 'just going through a phase', and that the symptoms will go away by themselves.
• Often the symptoms that the individual is experiencing makes it very unlikely that he/she will seek assistance. Some of the symptoms present very real barriers to an individual seeking help include: lack of motivation and energy; feelings of hopelessness; the belief that nothing will make a difference; and difficulties with concentration and memory. When such symptoms are present, families and friends have a particularly important role to play in encouraging their loved one or friend to seek treatment.

Specific treatment approaches

The various treatments available for depression are generally very effective and reliable, and the majority of individuals who experience depression can expect to the return to their usual selves following skilled treatment and management. It should be expected that a successful treatment outcome may take some months to be achieved.

The precise treatment that an individual will receive will differ from patient to patient, and will also be different depending on the type of mental health professional providing treatment. In general, treatment may include the following:

Assessment

This is the first step in any treatment and its importance in diagnosis has already been considered. Assessment will require having an interview with a mental health professional, such as a psychiatrist or clinical psychologist. This specialist will spend time getting to know the person and his/her circumstances and will ask about the symptoms that the person has been experiencing. Sometimes people find it hard to admit that things have been difficult, but in order for the professional to correctly assess symptoms and provide the best treatment, it is important to be honest and open about what has been occurring.

Medication

This will probably be prescribed since it is a very important part of treatment for depression. Medication restores certain healthy chemical patterns in the brain; can help to lift the person's mood; can help to overcome feelings of fatigue and lethargy; can improve memory and concentration; and can also help return a sense of pleasure to life. Often people are reluctant to take medication for depression, partly because they often fail to understand that depression is a very real illness and think of it rather as some form of personal or moral weakness. However, depressive illness has a substantial physiological component, which needs to be corrected, and this component is particularly prominent when symptoms are severe. In such a situation antidepressants are an essential part of treatment. If an individual is reluctant to take medication it is very helpful to talk over these concerns with a doctor or psychiatrist.

Classes of antidepressants

There are a number of antidepressant medications available and the amount and type taken varies from person to person. The treating doctor will provide the individual with information about how much and about when to take the medication. Sometimes the doctor will try several different medications, or combinations of medications, until the best one for the individual is found. Some of the classes of antidepressants are:

• Selective Serotonin-Reuptake Inhibitors (SSRIs)
  e.g. citalopram, fluoxetine, fluvoxamine, paroxetine, sertraline.
• Serotonin-2 Antagonist/Reuptake Inhibitor (SARI)
  e.g. nefazodone
• Selective Serotonin/Noradrenaline-Reuptake Inhibitor (SNRI)
  e.g. venlafaxine
• Noradrenaline and Selective Serotonin Antagonist (NaSSA)
  e.g. mirtazapine, mianserin
• Monoamine Oxidase Inhibitors (MAOIs)
  e.g. phenelzine, tranylcypromine
• Reversible Inhibitors of Monoamine Oxidase (RIMAs)
  e.g. moclobemide
• Tricylic Antidepressants (TCAs)
  e.g. amitriptyline, clomipramine, imirpramine, nortriptyline, doxepin, dothiepin, trimipramine.
  

Regardless of which medication, or combination of medications, is decided on, the medication will be monitored by the prescribing specialist and if side effects develop, the doctor may make changes to the amount or type of medication being taken. It is important that people report any side effects to their doctor so that steps can be taken to reduce adverse impacts. The pattern of side-effects and their intensity can give the specialist doctor useful clues as to whether or not effective levels of medication are being achieved or, indeed, exceeded. One common reason that people don't take their medication is because of unpleasant side effects and good communication with the doctor about side effects can help to ensure that people don't stop taking their medication prematurely.

Electro-convulsive therapy (ECT)

This is a very effective method of treating people with some of the more severe forms of depression, including depression that hasn't lifted despite intensive treatments with other forms of therapy. (For additional information see the brochure Electro-convulsive therapy.)

Psychological therapy or counseling. There are some effective psychological treatments available for depression. Research has shown that cognitive behavioral therapy (CBT) and interpersonal therapy (IPT) can be as effective as medication for treating mild to moderate depression. (For additional information see the brochures CBT & IPT.

Research has also shown that people who engage in these therapies are less likely to experience a relapse of depression than people who take medication alone. In part, this is because psychological therapies help the individual to identify and change the factors that contributed to them becoming depressed. However, when depression is severe, difficulties with concentration, memory and motivation can make it difficult to engage in psychological therapy. Especially in these circumstances, medication can help improve symptoms to a point where the person may then be able to benefit from psychological therapies.

The exact goals of psychological therapy differ according to the type of therapy being undertaken and the individual's circumstances. However, some of the goals of psychological therapies would be to:

• understand, identify and attempt to change the factors that contributed to the person becoming depressed. This might include identifying and modifying unhelpful ways people view themselves and their world, or identifying and altering problematic patterns of interacting in important relationships;
• learn to recognize and monitor the individual's personal 'early warning signs' of depression so that symptoms can be caught early;
• learn strategies that might alleviate the symptoms of depression when they arise;
• reduce the occurrence of problems that can go hand-in-hand with depression such as anxiety, or alcohol or other drug abuse;
• enhance the individual's quality of life; and
• return the individual to his/her usual life and usual daily routine.

Involuntary Admission

Sometimes it can become necessary for a person to receive involuntary treatment for depression in hospital. Such involuntary hospital treatment is reserved for situations when the person is at imminent risk of hurting themselves or other people.

For example, the person might be seriously and actively considering suicide, or may have already tried to harm themselves. In such situations, hospitalization helps ensure that people are properly assessed and treated so that they and others can remain safe.

When people are admitted in this way to hospital against their will or without them having given consent, this is called involuntary admission. In these cases, treatment is continued in a voluntary environment as soon as possible. (For additional information see brochure 'inpatient treatment'.

What is a crisis?

Sometimes individuals who are experiencing depression and their families can find themselves in very difficult and anxiety-provoking situations. They may be in a state of panic and uncertain what to do; they do not know if the situation is a crisis of some sort or an emergency that warrants medical or other professional intervention. In these circumstances it is wisest for the individual and/or the family to trust their feelings: if they are feeling unsafe, overwhelmed, afraid or unable to manage, then prompt action to seek help should be taken. Some crisis situations include when the individual:

• talks about or tries to hurt or kill themselves. All threats or gestures of self-harm need to be taken very seriously, and help needs to be sought straight away;
• seems capable of harming others, or is threatening to inflict harm; and
• has stopped eating or drinking.

Where to seek help in a crisis

In a crisis or in emergency situations like those outlined above, there are several agencies that may be contacted:

• Emergency department of the local hospital. Families can try to gain the person's cooperation to accompany them to the local hospital. If the person does not agree to this then other action needs to be taken.
• Police. Calling the police may be particularly appropriate especially when there is a risk that the individual will harm themselves or somebody else. In situations like this,the police will normally assist by escorting the person to hospital to be assessed by a specialist. The individual will then be able to get the help that he/she needs.
• Emergency psychiatric teams. The local telephone directory may list the number of local emergency psychiatric teams, which can respond in a crisis. Like the police, these teams will usually assist by escorting the individual to hospital where he/she can be assessed and, if necessary, treated by a specialist.
• Ambulance. Self-harm and attempted suicide are extreme emergencies. People are urged to call an ambulance immediately and ask for directions about what to do while waiting for help to arrive.

Understandably, crisis situations can be extremely frightening and traumatic for the individual and his/her family. It is important for families to support one another at these times and to establish a good relationship with the mental health agencies that are assisting them. After the emergency situation has passed it is often helpful to talk through the emergency with various involved family members or friends. Families may also ask to meet with a mental health professional to talk through various aspects of the emergency.

Especially after a crisis situation, families and friends need to ensure that they look after themselves properly, and this includes discussing what happened, discussing how the members of the family feel about what happened and planning to get back into a normal routine.