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
· 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
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)
clomipramine (Anafranil, Placil)
nortriptyline (Allegron, Nortab)
doxepin (Sinequan, Deptran)
examples of MAOIs -
SSRIs - Serotonin Specific Re-uptake Inhibitors
fluoxetine (Prozac, Lovan, Zactin, Erocap)
SNRIs - Serotonin Nor-adrenaline Re-uptake Inhibitors
5-HT2 receptor blockers
RIMAs - Reversible Inhibitors of Mono-Amine oxidase
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
flupenthixol (Fluanxol depot)
fluphenazine (Anatensol, Modecate)
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
diazepam (Valium, Ducene)
oxazepam (Serepax, Murelax )
alprazolam (Xanax, Kalma)
sleepers - very useful when used appropriately
temazepam (Euhypnos, Normison)
Lachlan Dunjey PO Box 68 Morley WA 6943
2/94 revised 12/97