Faces of depression


By Dr. Dewasmika Ariyasinghe (MBBS,MD-Psych),

(The names of patients used in

this article are not real.)

Amila is a 30-year-old woman. She works as a directress in a private company and is a mother of two children. She had been happy with her children and husband until one year ago. Since few months, she has been fighting with her husband and always felt that she was unloved and unattended. She wanted to get a divorce and she contacted her friend who is a doctor to find a good lawyer. The friend could not believe what she was hearing, but suggested that she should see a psychiatrist before going ahead with legal procedures.

Though reluctantly, she went to see a psychiatrist as she thought it would be helpful for her children. On further questioning it was revealed that she has depression.

Kapila is a 70-year-old retired teacher. His children are living abroad. He had been with his wife until her death, 3 months back. They were very close to each other. His children and grandchildren talk to him daily on Skype.

He is on treatment for diabetes and hypertension with good control.

One day when the couple who were looking after him, came home after buying groceries, they saw Kapila lying unconscious in the sofa. They hurried him to the hospital. On admission, he had very high blood sugar and blood pressure. Even after regaining consciousness he appeared sad and preoccupied. He was directed for a psychiatric assessment. Kapila revealed that he stopped taking treatment thinking that it would kill him, as 'there is no point in living'. He was found to be severely depressed.

Isuru is a 35-year-old accountant. He lived a peaceful life with his two children and his wife. He was a social drinker and never exceeded his limits. But since of late his wife noticed that he has increased his alcohol, both the frequency and the amount. When his wife, Malika inquired about this, they ended up fighting with each other. Since, Malika had similar experience with her brother, and he got better after seeing a psychiatrist, she went to see a psychiatrist and told him that Isuru was quite withdrawn, hardly talked to them and that he had lost weight. On advice of the psychiatrist she managed to take Isuru to see him. Isuru revealed that he was very worried about the future of their children and he found it hard to relax. When he first took some alcohol, it made him feel better and even without his knowledge, the alcohol intake went up. The psychiatrist decided that Isuru was suffering from depression.

Twenty-four-year-old Tharuka was looking forward to her first baby. After knowing that the baby was a girl, she prepared to welcome her enthusiastically. Her husband, Mahesh was always there for her.

She delivered a baby girl and the couple were extremely happy. She was discharged home early, as there were no complications.

One week after the delivery, Mahesh noticed some changes in Tharuka, but ignored them thinking that she might be tired looking after the baby. But she became increasingly negligent of her baby and her mother had to force the baby to her breasts to feed. She was not keen to attend the baby's needs of her own. Her smile, which was there all the time was gone.

Thinking that it is 'Vadu gei sanniya', the family organized a 'thovilaya'. The next morning, Mahesh saw Tharuka running towards the well, with her baby. He managed to catch her just before she jumped into the well. ' Let me and the child die. Don't let us suffer' Tharuka was screaming at the top of her voice.

She was taken to the hospital with great difficulty. On the way to the hospital, she tried to jump out of the vehicle to commit suicide. She was diagnosed to have post-partum depression.

How does depression change our behaviours, thoughts and performances?

A person who is depressed tend to think about himself, future and the world (experiences) in a negative manner.

Though there was no change in the way Amila's husband cared for her, because of her own change in the way of thinking due to depression, she thought 'he does not love me anymore', 'he may be having other women', 'no point in continuing with this marriage' and decided it was worth going for a divorce.

Isuru felt that he was an incompetent father and lost confidence in him. He was not sure that he could look after his family. He started to use alcohol in increased quantities as he felt temporarily better with alcohol.

Tharuka lacked motivation and energy to attend to her and baby's needs. She felt that she was not a 'good mother' and decided it was better to take her life as well as her baby's.

The common symptoms we see in patients suffering from depression are difficulty in concentration, irritability, poor sleep, body aches and pains, lack of courage/enthusiasm/motivation, impaired memory, difficulty in coping with day to day demands, making uncharacteristic mistakes, deteriorating performances at work/ school/ academic activities, lack of desire to have sex, using substances of abuse, feeling that the life is not worth living and having suicidal ideas and withdrawing from social life.

Is depression only about what we 'see'?

1. Detrimental effects on brain:

When depression is not treated properly, there are certain changes happening in the brain especially in the area known as hippocampus, which plays a major role in our memory. If the damage goes for a long time the patient can even end up developing dementia later in life.

2. Depression and the immune system:

The immune system is adversely affected by the presence of untreated depression. Inflammatory conditions (eg; Rheumatoid arthritis, bronchial asthma) can aggravate when there is concomitant depression and chronic inflammatory conditions can lead to depression. Due to various effects of depression on the immune system, its ability to ward off infections and cancers can also be impaired.

3. Depression and physical illnesses:

A person who suffers from a long term physical illnesses like hypertension, diabetes and heart diseases has a higher chance of developing depression. If depression is not treated while treating these conditions, this can affect the outcome of these as well. Take a patient who has suffered a 'stroke'. He has to undergo extensive rehabilitation, which needs lot of effort from the patient, to regain his lost functions.. If patient becomes depressed, he loses motivation and energy to involve in these sessions. In addition, his negative views of the situation 'nothing will work for me, I will never be the same again' further keep him away from rehabilitation, gravely affecting his recovery.

Furthermore, some people tend to engage in unhealthy behaviours, when they develop depression; eg; sedentary life style, consuming alcohol, smoking and consuming unhealthy foods. So, they can develop illnesses like diabetes, hypertension and heart diseases.

4. Depression, maternity and the newborn:

Normal physical and psychological development of a newborn depend a lot on his mother. The initial bond (attachment) between the baby and the mother is vital in important aspects of his life; establishing healthy relationships in the future and see the world as a trustworthy place. A mother suffering from depression is unable to respond to emotional needs of the newborn. Sometimes the mother can beat the newborn when she actually should be hugging him.

5. Depression and family disputes:

It can be very hard for the family members to live with a patient who has untreated depression. Frequent crying, complaining, nagging, neglecting responsibilities/duties and irritability are some of the distressing problems which can take away the peace of mind of everyone.

6. Depression and employment/work:

Depression reduces motivation, impairs judgement, slows the speed of work, reduces attention and memory. So even if the person attends to work, his efficiency is very much reduced (presenteeism). Some may not go to work at all (absenteeism). Due to irritability, they can get into unnecessary problems. Therefore, the person runs the risk of losing the job. The economic growth of a country can also be affected greatly due to inefficient work force

7. Depression and alcohol/drugs:

People suffering from depression, may start to consume substances, which may give them temporary relief. If they continue to use these thinking that they give relief they can develop a serious mental illness named dependence. Likewise, the people who abuse these substances are more likely to develop depression.

8. Depression and suicide:

Majority of those who commit suicide have been found to be depressed. A significant proportion of people who attempt suicide also have depression. At times, a parent may poison children and later commit suicide, thinking that 'there is no way out', 'if only I die the children will be unsafe'. This type of negative thinking is common in patients with depression.

We will now see the outcome of the examples mentioned at the beginning of this article.

Amila was started on treatment. After about a month, she started to feel 'different'. She told the psychiatrist that there was no need for a divorce as 'it was myself who changed not my husband'. Her husband was happy and relieved as he got his pleasant and cheerful wife back.

Since Kapila was severely depressed and was suicidal, the psychiatrist suggested him taking electro-convulsive therapy (ECT). But he was hesitant. After the psychiatrist explained him that it is a safe, very effective and widely used method of treatment, Kapila agreed to go ahead. He was started on medications as well. After undergoing six sessions of ECT he was well. In his own words 'I gain my senses back' and he thanked his helpers for taking him to the hospital just in time. After 2 months he left to Australia, while on treatment, to spend 6 months with his children. He promised that he would see the psychiatrist after he return to get a new prescription.

The psychiatrist prescribed an antidepressant to Isuru and recommended him medical leave for one week. After three weeks they came to see the psychiatrist for a review. Gradually their life was getting back to normal and Isuru had given up alcohol completely.

Since Tharuka was suicidal and it was important that she attended the baby as soon as possible, she was started on ECT and medications. Mahesh asked whether it was safe to breastfeed while taking treatment and the psychiatrist informed that it was. Tharuka improved with four sessions of ECT and she was seen breastfeeding and cuddling the baby. On discharge she was advised to continue treatment and to attend the clinic regularly. In addition, the couple was asked to use a reliable contraceptive method at least for another year, as unplanned pregnancy could worsen depression, adversely affect the foetus, the baby and the whole family.

It is now understandable that depression is a treatable illness and not a 'weakness of one's mind'. It is a very common mental illness and about 10 out of 100 people suffer from depression. It is an illness anyone can possibly get because we all have a brain! There are important factors to be kept in mind about treatment of depression. The medications given are not addictive nor are detrimental to the brain. It can take about 2 weeks to feel some improvement. Treatment has to be continued even after symptomatic improvement, until the psychiatrist decides that it can be stopped. The side effects are not life threatening and there are several categories of medications to choose from. It is important that you let know your psychiatrist of the side effects and he can change your medication. Once the patient improves he can function like anyone else, while continues to take treatment.

(The writer is Senior Lecturer, Department of Psychiatry, Faculty of Medicine, University of Peradeniya and Honorary Consultant Psychiatrist, Teaching Hospital Peradeniya.)

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