DEPRESSION - some
notes for counsellors
· has many
faces - but should not be confused with physiological grief or sadness -
depression is never physiological - some use the term very loosely
· has many
causes and is usually multifactorial, but end-point is always the same in that
neurotransmitters are affected - cf. asthma where the end-point of spasm is the
same regardless of the cause
· has many
therapies and many therapists may be involved
· if a
person is severely depressed, not only do they have no power to lift themselves
up but analytic therapies or cognitive-behavioural therapies at that point may
risk making them worse by aggravating their sense of failure, or worsening
their ruminating thought processes or guilt, or just overwhelming them with the
severity of the trauma of which they are reminded and of their own hopelessness
· counselling
at such times should be supportive, reassuring, giving hope, e.g. 'now is a
time for rest, not thinking, not struggling, just resting physically, mentally
and spiritually - we will help with the other problems later'
· 'it's OK
to feel - if you can, just jot your feelings down on paper, but DO NOT analyse,
or question their rightness or wrongness'
· be aware
of the possibility that issues that have been completely dealt with and
integrated sometimes come to the fore again in depression (because of the
depression) - the depression needs to be treated first and then see what needs
to be done
· some
depressions with a strong genetic biochemical component 'only' need chemical
treatment (plus supportive counselling as above) and then their cognition
changes, their values and constructs change for the better, and they do their
own problem solving! It is really quite amazing (and frightening) how much our
cognition is dependent on our chemistry. Follow-up counselling is always
appropriate in these people to enhance understanding of the problem, to learn
appropriate stress avoidance or management, and to be aware of warning
indicators.
POSSIBLE REASONS FOR REFERRAL TO A DOCTOR
· significant
depression e.g. with impaired emotional responsiveness, withdrawal, difficulty
in coping, suicidal thought.
· delusional
thought, voices, out of touch with reality.
· obsessive-compulsive
aspects e.g. obsessive ruminating thought processes.
MEETING AT POINT OF NEED
· just a
'needless' reminder that it can be quite useless - in fact, worse than useless
- to be prompting on issues of past sexual abuse when their house has just been
burnt down or their child attempted suicide.
· there may
be a time to put specific counselling 'on hold' for an agreed period of time,
and usually there is no difficulty in knowing when it can be re-started.
MEDICATIONS for
depression
ANTIDEPRESSANTS
· actually
make people better - not just make them feel better
· work by
restoring the neurotransmitter levels
· are NOT
mood elevators in non-depressed people - they make them feel bad!
· are NOT
personality changers
· are NOT
addictive*
· are NOT
related to tranquillisers.
· dosage
does not necessarily correlate to severity - some seem to need higher doses to
achieve the same drug level (a therapeutic level) because they metabolise
differently
· usually
take between 1 - 3 weeks to work
· do NOT
hinder counselling, but enhance it by facilitating normal emotional responses
· do NOT
cause loss of control - they enhance it
· never a
substitute for counselling - the hard work still has to be done
· should not
be used in grief unless depression is also present - good grief helps prevent
depression
· useful in
'mild' depression when it has been present for a long time
*while there are some withdrawal effects with some of
the newer agents, in general it is true to say that the longer a person is on
an effective dose of an effective antidepressant the easier it is to come off
it i.e. it is no longer necessary
SIDE-EFFECTS OF ANTIDEPRESSANTS
· vary with
type of medication as well as from person to person and should be discussed
with the doctor
· are
generally of the 'nuisance' type and ease with time
· are dosage
related, diminish with reduction of dose and leave no residual effects
· some are
sedative for some and stimulating for others and therefore need to be
individualised
· with the
older drugs a dry mouth is inevitable if dose is sufficient
· some may
experience nausea, constipation, blurring of vision, slowness of urination,
interference with libido or ability to climax, dreaming (vivid and bizarre -
need reassuring that it's due to drug), light-headedness due to low blood
pressure, tremor
· the
presence of side-effects does NOT necessarily mean the dose should be modified
or the drug ceased - that depends on the severity, other medical factors and
suitability of other agents
· mono-amine
oxidase (MAO) inhibitors need to be very carefully managed in cooperation with
the doctor, but the newer 'reversible' inhibitors do not have the same
restrictions
EXAMPLES OF ANTIDEPRESSANTS
confusing due to the rapid
proliferation of designer drugs i.e. being designed and manufactured to achieve
a specific biochemical purpose in a specific area
older antidepressants
include the tricyclics,
tetracyclics, mono-amine oxidase inhibitors (MAOIs) and Lithium - better known
for its mood stabilising effects in bipolar disorder (manic-depression)
some examples - common brand names
in brackets
dothiepin
(Prothiaden, Dothep)
amitriptyline
(Tryptanol, Endep)
imipramine (Tofranil)
clomipramine
(Anafranil, Placil)
nortriptyline
(Allegron, Nortab)
doxepin
(Sinequan, Deptran)
mianserin
(Tolvon)
examples of MAOIs -
phenelzine
(Nardil)
tranylcypromine
(Parnate)
newer antidepressants
SSRIs - Serotonin Specific
Re-uptake Inhibitors
fluoxetine
(Prozac, Lovan, Zactin, Erocap)
paroxetine
(Aropax)
sertraline
(Zoloft)
fluvoxamine
(Luvox)
SNRIs - Serotonin Nor-adrenaline
Re-uptake Inhibitors
venlafaxine
(Efexor)
5-HT2 receptor blockers
nefazodone
(Serzone)
RIMAs - Reversible Inhibitors of
Mono-Amine oxidase
moclobemide
(Aurorix)
ANTIPSYCHOTICS
previously referred to as major
tranquillisers but are not 'strong'
- major refers to how they work rather than severity of condition
usually used for 'psychotic'
features or difficulty in controlling thought processes, extreme restlessness
or agitation, or hypomania
Examples -
thioridazine
(Melleril)
trifluoperazine
(Stelazine)
haloperidol
(Serenace)
pericyazine
(Neulactil)
risperidone
(Risperdal)
olanzapine
(Zyprexia)
flupenthixol
(Fluanxol depot)
fluphenazine
(Anatensol, Modecate)
ANXIOLYTICS
previously referred to as 'minor'
tranquillisers
very useful if used as temporary
enhancement of coping ability
should never be used to substitute
for grief
do not have any antidepressant
effect (except for Xanax) and should not be used for primary treatment of depression
all have dependency potential
Examples -
diazepam
(Valium, Ducene)
oxazepam
(Serepax, Murelax )
lorazepam
(Lexotan)
alprazolam
(Xanax, Kalma)
HYPNOTICS
sleepers - very useful when used
appropriately
Examples -
temazepam
(Euhypnos, Normison)
nitrazepam
(Mogadon,Aloderm)
Lachlan
Dunjey PO Box 68 Morley WA 6943
2/94 revised 12/97