The phrase “I feel depressed today” or “This has been such a depressing week” are so commonly used, that it often diminishes the suffering of patients with depression.
Thus, in this expert article, Gleneagles Kuala Lumpur Consultant Psychiatrist, Dr Lu Ann Chong explains the mental illness as Clinical Depression or clinically depressed to clearly distinguish it from the more often used form of “depressed”.
Clinical About Depression
Clinical Depression is a condition that is very different from feeling low. Firstly, there is a strict diagnostic criteria that trained specialist adheres to make the diagnosis. In order to fulfill the criteria for clinical depression, one must have pervasive low mood that is sustained for at least two weeks. In addition, there is a reduction in energy levels and loss of capacity of enjoyment. Interest and concentration is also reduced.
Sufferers complain of marked tiredness after even minimum effort. Sleep is usually disturbed and so is appetite. There can be a decrease or increase in sleep and appetite. There is loss of self-esteem and self-confidence, alongside ideas about feelings of guilt and worthlessness. These can often be accompanied by suicidal thoughts and without proper intervention, suicidal acts itself.
There are no blood tests or concrete investigations that can produce a diagnosis, and therefore skilled talking sessions with psychiatrists can differentiate between clinical depression, which is serious and require treatment, from normal everyday sadness.
Depression Across Age Groups
Children and Teenagers
There is a misconception that childhood is a time where one is free from responsibilities and has the freedom to enjoy life. It is often inconceivable to adults that a child may be unhappy to the degree that he or she develops clinical depression. Society has changed so rapidly that there are tremendous pressure on young children and adults. This includes the increase in divorce rates as well as in environments where the parents choose to stay together for the sake of the children but unintentionally subject their children to choose between parents in arguments and bear witness to scenes where ugly words are exchanged. While these are the more common reasons within the family context where clinical depression can arise, physical and sexual abuse are contributors too.
For children in their early teens, clinical depression present more atypically as physical ailments. For example, persistent and unexplained abdominal pain, social withdrawal and refusal to attend school. Children in mid to late teens with clinical depression may engage in multiple forms of destructive behaviour. Recreational drug usage can be seen as a form of self-medication. Mixing with the ‘wrong type’ in school may be a result of needing approval of a peer group, a feeling of belonging that the young adults do not experience at home. There are children that self-harm by using sharp objects to cut their forearms or other parts of their body, causing superficial injuries.
More dangerously, there are young women and men who overdose on prescription or illegal drugs. Assessments of these suicidal attempts have to be done carefully to distinguish between action and intent. Most are what we commonly refer to as ‘cry for help’ as opposed to a genuine desire to die. Young adults that engage in this sort of self-harming behaviour do not necessarily have clinical depression. It arises from a maladaptive form of coping with stress and rejection.
In fact, it is very common for a young adult who has self-injured to express a sense of relief on doing so. When gently questioned further, most will say that the pain they incur on themselves helps relieve the feeling of numbness or stress they feel inside. All suicidal attempts have to be assessed individually to rule out clinical depression. However, it is not a given fact that it is a presenting symptom of clinical depression.
One useful way to look at reasons why someone presents with clinical depression at different stages of their lives can look at what type of challenges that person will typically face and have to overcome at that particular stage of life. Young adults in their late teens and early twenties are struggling with finding or defining their own self-identity.
This is a case example on identity and role confusion. Mr B is a 24 year old accountant who suffers from feelings of guilt about his homosexuality. He dreads any family social event where he is often asked about girlfriends. He feels that as the only son in his family, he is letting his family down. He feels like a fraud. He tries internet dating and met with some unpleasant encounters that increases his feelings of guilt, shame and self-loathing that slowly develop into clinical depression.
Mid to Late 20s
Adults in their mid to late twenties have another major life challenge – overcoming feeling of isolation and achieving intimacy with another person. Most of the clients that I see in their mid-twenties and early 30s talk about this a lot. Many have disappointments, ranging from finding out about infidelities to breakup of a long-term relationship. Those that don’t deal with rejection, abandonment and loss are the children who come from broken families themselves. Many women who enter into abusive relationships are often a result of a vicious cycle of abuse they themselves have encountered as young children.
Modern society makes demands of one finding a soul mate, someone that ‘completes you’. This is a misleading concept. One should be independent and confident on their own and their life-long partner is one that compliments them, not complete them. This can result in feelings of loss and abandonment that can lead to clinical depression. Statistically, women are twice as likely to be clinically-depressed compared to men.
Men and women having navigated through the tumultuous years of asserting their own self-identify and also successfully paired up in a healthy relationship face the next big milestone in their life – work.
Adults between 30 and 40 years old
The clients that I see in their 30s and 40s are mostly concerned with stress at work, dealing with difficult bosses; feeling that they don’t earn enough; the instability of the job market; the feeling that they do not have passion in the work they do. These are all modern phenomena. A generation or two ago, most of our forefathers will not talk about finding passion in their work. They work. They earn. They provide.
Women now have the freedom to work and those who do, have pangs of guilt about choosing work over their children. Women, who give up work for children occasionally, feel that they missed out on climbing the corporate ladder and the change in power imbalance in their relationship with their partner.
Overarching all of this is the concept of ‘status anxiety’. Status anxiety is the feeling that everyone else is doing better than you. Social media sites such as Facebook and Instagram amplifies this feeling that everyone else is travelling more, hanging out and eating in more interesting places, having more interesting friends, generally having an overall more interesting life that you do. Women are more likely than men to seek help if they feel that they may be depressed.
Most work-stressed men choose alcohol as a solace for the misery they feel. Alcohol by itself is a mood depressant. Excessive alcohol use can lead to alcoholism, which not only impacts their health in their 40s and 50s, but more directly, their work performance. All these are toxic ingredients to the onset of clinical depression.
Adults between 40 and 50 years old
Working men and women in their 40s and 50s are considered to be at the most productive period in their life. This cohort also holds more senior positions, have more responsibilities and tend to work harder than their younger counterparts. They have more on their shoulders. Mortgages, children education and keeping their health insurance makes any threat of job loss incredibly anxiety-provoking.
Ironically, those that are stable in their job start to feel that they are stagnating if they are not being promoted. Job losses, fear of job loss, fear of lack of promotion, severe unhappiness and stress at work leads to exhaustion, burnt-out and clinical depression. Advice to slow down and take a break on the job front is often not listened to, due to status anxiety, as mentioned earlier.
Adults above the age of 50
Poor health is the major concern of those above 50 years old. Chronic illness, especially those associated with pain symptoms are most likely precursor to development of clinical depression. Those approaching death, start asking existential questions about the life they have lead, any legacy they have left behind, any impact they have made for society or their children and grandchildren. There are often regrets over failed relationships with loved ones.
Life Conflicts
Across all decades of life, clinical depression presents with similar symptoms, as I have outlined in the beginning. The reason why people become depressed at different ages depends on the major life conflicts they have to face at that time. Knowing what these are means that there are possibilities to put in safeguards to help people gain access help. For example, counselors in school settings will be a safety net for children and young adults to get access to psychiatric help.
Work organisations can incorporate friendlier staff at the Human Resources Department to understand why someone may be struggling at work. Referrals to general practitioners from Human Resource to screen for mood disorders can be the first step to referral to psychiatrists.
The Psychiatrist’s Role
The role of a psychiatrist is to first offer a confidential, non-judgmental setting where the client feels safe in sharing what their troubles are. When the clients openly share their worries, problems and concerns, a skilled psychiatrist can pick up symptoms to alert them to the presence of clinical depression or not, asking open questions in a non-directive manner.
This form of conversation exchange is more natural and intuitive in approach to correcting, detecting and confirming clinical depression compared to the ‘tick box’ approach to asking direct questions. As I was recently reminded, when reviewing a patient at the ward who happened to be a Consultant Specialist herself, when I greeted her with a friendly, “How have you been feeling?”, she replied, “The patient always lies.”
The right treatment starts with the right diagnosis. The often repeated statements that antidepressants do not work is because they are often given to the wrong type of patients. There have been many years of high quality research on many different types of antidepressants, and the role of a psychiatrist is to first make the right diagnosis.
Prescribing antidepressants is easy to do. Prescribing the right antidepressants to the right patient group takes skills. More importantly, there is no single best antidepressant. Different antidepressants have different side effects profile, depending on the age, gender and health condition of the patient.
Besides simply prescribing medication, psychiatrists offer a safe place where the patient is able to ventilate their worst fears without the deep seated fear of rejection that almost all of us have about people holding judgments over us. That simple process of being able to talk is just as important as medication.
Dr Lu Ann Chong’s sub-specialty is Liaison Psychiatry where she covers the interface between medical presentations with co-morbid Psychological/Psychiatric distress. She has specialist training and interest particularly in Young Onset Dementia and Perinatal Psychiatry (Antenatal and Postnatal Anxiety/ Depression).
