Article: Dealing with depression and mental illness

This was published yesterday, as the main feature in the Sunday Business Post’s Agenda Magazine. It’s been posted online at the paper’s website, but for some reason, the panels and extra bits and bobs don’t seem to make it onto the website when the main site is updated, so I’ve included them here.

Recession depression
Published in The Sunday Business Post on October 18th, 2010, by Alex Meehan

Ever wondered what the most dangerous occupation in Ireland is? Bomb disposal expert perhaps? Or maybe a steeplejack? In fact, when it comes to your physical and mental health, being unemployed is by far the most hazardous occupation you can have.

With unemployment now standing at just under 14 per cent of the population, Ireland’s GPs are seeing a wave of mental health issues affecting their patients. Many of them are coping with serious depression and anxiety for the first time in their lives as a result of deteriorating economic circumstances.

“The preferred state for a healthy human being is to be active and working and to be socially active. This feeds into our ideas and beliefs and important questions such as ‘who am I?’ and ‘am I in control of my own life?’” says Martin Rogan, assistant national director of mental health for the HSE.

“Work is an essential component of a happy life, of getting the balance right. Ideally you’d spend around a third of your life, or half of your waking time, in some purposeful and constructive employment that allows you to provide for yourself and your family and ideally which makes some sort of contribution to society. These are very strong cultural needs that people throughout the world recognise. If you can’t fulfil these needs, then it’s almost as difficult as not being able to sleep or eat,” he says.

According to Aware, over 300,000 people in Ireland suffer from depression at any given time, and one in four people will experience it during their lifetime. Women are three to four times more likely than men to suffer from the illness and if left untreated, depression can be fatal as it can lead to suicide.

“There’s no doubt that the recession has impacted people’s health very significantly,” says Dr Abbie Lane, consultant psychiatrist and head of the Dublin County Stress Clinic at Saint John of God Hospital. “It’s led to episodes of depression in people who have never experienced anything like that before, and it’s certainly led to an increased rate of suicide as well.”

According to Lane, a key challenge for people coming to terms with a major life change such as losing their job lies in confronting their own self image.

“Many people have a tendency to equate their self worth with their job, and when that’s taken away from them they’re left wondering who they are. We’re seeing people who are depressed and anxious because they’ve lost their job, their financial security, maybe the loss of the future they’d been planning but now can’t afford,” she says.

“There is also a gender bias – this affects men worse than women. Men traditionally see themselves as providers and as the person who looks after the family, but in our society it can increasingly be the case that women can earn more or be the sole earners in a house.”

Lane believes personal make-up has a lot to do with how well someone adjusts to a new situation. “Men who find themselves unemployed can suffer an awful sense of loss and can experience shame and embarrassment. To be fair lots of men don’t feel this at all – it depends on the individual, their make-up and their circumstances — but it tends to effect men more than women,” she says.

“If someone proactively decides to be a stay-at-home dad or a house husband, then that’s a different thing to having that thrust upon them as a result of them becoming unemployed.”

Massive advances have been made in recent times in the diagnoses and treatment of depression, anxiety and other forms of mental illness in Ireland. However attitudes to people suffering from these conditions have not kept pace, and many sufferers are still reluctant to see their GP or even to recognise that what they are suffering from is in fact a mental illness.

So strong is the stigma that surrounds the idea of mental illness that it’s quite common for sufferers to reach breaking point before they will seek help.

“When you have a mental illness, you don’t look any different to the people around you even if you’re suffering inside. You may seem perfectly fine but the subjective experience can be very different,” says Martin Rogan of the HSE.

“Around 16 million incidents of primary care – in other words people visiting their GP — take place every year in Ireland, and of those, around 35 per cent relate to mental health. It’s an enormous invisible issue. It’s invisible for a number of reasons, mostly because of the massive stigma around it. It’s effectively an iceberg issue, in that only the tip is visible.”

According to Rogan, one of the reasons for the stigma that still surrounds mental illness is the historical manner in which it was treated.

“Our tradition of dealing with these problems in Ireland is rooted in the use of big institutions. In 1950, Ireland had the world record for institutionalising people. We basically took the British model, which was designed to help that country run an empire, and applied it here,” he says.

“In 1950, we had 22,000 people, or 0.5 per cent of the population, living in psychiatric hospitals. By the time I started my career in 1983 that number had come down to 12,000 and today, there are 1,200 beds in the system.”

The reason for such a sharp drop in the number of people in the care of the state is partly to do with advances in medicine and treatment, and partly with the way mental illness was defined in the 1950s.

“The old system was less discriminating – people with learning difficulties made up almost half of all people in these institutions and almost half of all admissions related to alcohol. They were often a way for society to deal with people who were vulnerable; it became a total solution to admit them. Instead of these people being given a service by the state, they were almost adopted by the service,” says Rogan.

“Famously, women coming out of Magdalene Laundries often ended up in them, and children emerging from orphanages and care situations sometimes graduated from industrial schools to their local psychiatric services.”

While many of these people should never have been in these institutions, for those with genuine mental illness, little could be done.

“We’ve become much more sophisticated since then and the technologies available to us to help people have dramatically improved, not just in terms of medication but also in terms of how we understand mental illness and what we can do for people,” says Rogan. “Things like cognitive behavioural therapy and other therapies have all made a huge difference to how we help people today. Not only are fewer people being admitted to care, they’re staying for much shorter periods of time and we’re getting much better outcomes.”

One of the major differences between how illnesses such as anxiety disorders and depression were dealt with in the past and today is the degree to which therapy is used to resolve the problem.

“In the past, anxiety used to be managed by substances called benzodiazepine, usually in the form of valium or sleeping pills, but they were all highly addictive. Nowadays we don’t use them, we use low doses of an anti-depressant in conjunction with therapy,” ” says Dr Abbie Lane.

“Therapy is really the key in anxiety disorders; the aim is to give people the tools to become their own therapist, to learn new coping skills, and that’s a huge part of the success of these treatments. Therapy can teach you how to live a lifestyle that increases your resilience and resistance to these types of illness, and also how to spot the early signs of the problem reoccurring.”

According to Lane, patients who are advised to see a therapist generally attend once a week for a few weeks, during which time the therapist will assess their situation, go through their thinking patterns and look into the issues that concern them.

“The therapist will also give them practical exercises, and that would go on for about six or eight sessions. Sometimes people need longer, but the majority of cases of stress related illness would respond to that form of therapy,” she says.

“Studies show that a certain number of people do need medication to effectively deal with their illness. People need medication if they have persistent anxiety throughout the day about everything around them, and are unable to shake it off. If they’re depressed, have low moods, loss of enjoyment in life and loss of motivation to do anything, or if their sleep is seriously affected, then medication can also be helpful.”

When medication is prescribed, it’s usually from a family of medicines known as SSRIs, or selective serotonin reuptake inhibitors.

“These are not sedatives at all and tend to be very well tolerated by people. These drugs come with some side effects but they tend to be minimal and patients describe them as manageable. They’re also safe in overdose – the older ones were cardio toxic and could create serious heart problems if someone overdoes on them. The new ones are much safer,” says Lane.

SSRIs work by re-regulating the body’s own serotonin control system, which is implicated in anxiety and depression, increasing the person’s own serotonin levels rather than artificially introducing a new substance. Usually, an SSRI is prescribed for a period of around six months.

“Often people feel well after a month of taking them, and may feel like they don’t need to continue, but they actually do because the risk of relapse continues for around six months. Obviously, it needs to be discussed with a doctor and the dosage gradually withdrawn after six months,” says Lane.

She believes that many people who are suffering from depression for the first time don’t realise they have the condition. “Even if they do realise it, they may not know how to get help, or they may think they have a serious psychiatric illness and fear talking about it or seeking help because of the stigma that’s attached to it,” she says. “People are often afraid that their illness will affect their future employability, their insurance records, their ability to travel.”

Both Lane and Rogan point to alcohol as a major contributing factor to depressive episodes.

“People under stress or pressure may reach for alcohol because it’s freely available and doesn’t cost much. But it’s important to realise that while alcohol may release the initial feelings of stress, it also increases anxiety and depression. People who experience those feelings should approach alcohol with caution,” says Lane.

Martin Rogan believes Ireland has an “extraordinary” problem with alcohol abuse.

“Over 40 per cent of people who kill themselves in this country have consumed alcohol, yet alcohol abuse is an issue that we just refuse to recognise,” he says. “It has a depressing effect and disinhibits people from doing things they might not otherwise contemplate. Many times, people turn to alcohol to self-medicate, when it would be much healthier to see a therapist to get some new perspective.”

According to Rogan, Ireland is actually a relatively good place to suffer from a mental illness, relative to the rest of the world.

“We have a very well developed and skilled workforce in this area in terms of primary care, and in terms of our mental health services. But even before people access these services, Ireland is a good place to live in terms of general quality of life,” he says. “As a nation we have undergone major change in our economic circumstances in recent years, but if you compare living here with living in the US or in many other European countries, particularly if you are depending on a public health service, we compare very well.”

“Your likelihood of developing depression is reduced if you have good quality housing, have a good prospect of work, live in a clean environment, have a good diet – your likelihood of developing depression are reduced. Quality of life is overall pretty good here,” he says.

But Rogan concedes that as the country moves into an era of austerity and cuts, there will be greater challenges facing those attempting to treat mental illnesses here. “In 1966, mental health services had 23 per cent of the national health budget. By 1984 that had fallen to 12 per cent, and by the time the Vision for Change document was published in January 2006, it had shrunk to 7.6 per cent of the health spend,” he says.

“That document set a target of 8.4 per cent for spending in this area, but according to the World Health Organisation, to have an adequate service around 12 per cent of your spend should be going on mental health. This means that we have to be extremely focused and super efficient in getting the most out of the money we have.”

PANEL: Are you depressed or just a bit down?

Occasionally feeling depressed is a normal part of everyday life but when does feeling down become a problem that requires a trip to the doctor?

“If something bad happens to you, it’s normal to become unsettled and to develop some anxieties and sleep disturbance. We call that acute stress reaction or an adjustment reaction, the person needs to get their bearings and adjust to what has happened,” says Dr Abbie Lane, consultant psychiatrist and head of the Dublin County Stress Clinic at Saint John of God Hospital.

“This typically happens if you lose someone close to you, but you can get the same symptoms with other bad news – if you lose your life savings, or are let go from your job.”

According to Lane, mild depression can turn into something more worrying if there is a pervasive low mood that lasts for more than two weeks, and that nothing will lift.

“If the person won the lotto in the morning they’d still feel the same, they wouldn’t be interested or motivated by it and basically wouldn’t enjoy it. At the same time, it’s also of concern if the intensity of the symptoms starts to interfere with how a person leads their life, with their function in work, with their family or socially. If those things are happening then it’s something that needs an intervention.”

“This is particularly true if someone decides life isn’t worth living and they’d be better off dead, that’s very serious,” she says.

According to Aware, depression has eight main symptoms and if a person experiences five or more of them, lasting for a period of two weeks or more, they should speak to a GP or mental health professional. The symptoms are:

* Feeling sad, anxious or bored
* Low energy, feeling tired or fatigued
* Under- or over-sleeping, or waking frequently during the night
* Poor concentration, thinking slowed down
* Loss of interest in hobbies, family or social life
* Low self-esteem and feelings of guilt
* Aches and pains with no physical basis, e.g. chest/head/tummy pain associated with anxiety or stress
* Loss of interest in living, thinking about death, suicidal thoughts.

PANEL: ‘Jennifer’ – My experience

“I was diagnosed with bipolar disorder around two years ago, but I’ve probably had it for most of my life.  A very troubling summer in 2008 brought the matter to a head. I’d been in denial for a long time, telling myself it was everyone else who had a problem, not me.

It got to the point where I was suicidally depressed, wasn’t able to get out of bed or get dressed – basically I was very down and I realised I couldn’t rationalise the situation any longer. I had to get help because there was obviously something wrong and I wasn’t able to fix it myself.

“Bipolar disorder has a big impact on the people around you – it was difficult for my family to see me so depressed, and it was obviously difficult for my friends who bore the brunt of my moods both when I was depressed and manic. I picked a lot of irrational fights that would spiral out of control and lead to me storming off. It’s not easy and they put up with an awful lot.

“Making the doctor’s appointment was one of the hardest things I’ve ever done. Saying out loud to a doctor ‘I think I’m depressed’ and then going home to tell my parents I had been prescribed anti-depressants was very hard. It was like I was acknowledging that there was something really broken about me. I was afraid people would shun me and think I was a weirdo, or someone who wasn’t capable of maintaining a normal life, but the truth is that actually I’m pretty successful — I have a good job, a great family and a great group of friends, I do really well for myself.”

“I embarked on the path with my doctor of trying to get the right medication, which wasn’t fun, and a year of weekly cognitive behavioural therapy, which involved talking and a lot of practical exercises to help me deal with the anxiety issues that go along with a manic phase and the issues that appear when I’m depressed.

“For me, my disorder manifests in mood swings. If your base mood is zero, then the average person experiences mood swings of between plus and minus five on that scale. For someone with bipolar, it can be between minus 20 and plus 20 – in other words there are real extremes of emotion. These extremes can be totally unrelated to what’s going on around them.

“Being down looks a lot like depression and is easily seen by the people around you. Mania, on the other hand, isn’t so widely recognised. You can be in a euphoric mood that can go up to and include psychotic episodes. I’ve never been that bad, but I have been in a frame of mind where I’ve made completely irrational, life endangering decisions.

“At the time they seemed totally normal and rational. My perspective was totally skewed – I’ve had days when I was supremely confident and I’ve believed myself to be almost omnipotent. I was untouchable in work and was going to make a fortune with my side business and no one could convince me otherwise.

“Since being diagnosed, I’ve been trying to get the right balance of medication to help balance my moods but not cripple me with side effects. The therapy side of treatment has involved lots of self-development; basically I realised I needed to come to terms with my condition. I have quite a few followers on Twitter and recently I started to publicly tell people I have this condition.

“Like it or not, I have a disorder and I couldn’t continue to ignore it. The truth is that in our society it would be easier for me to come out and say I’m gay than it would be to say I’m mentally ill.  Suffering from a mental illness is still a huge taboo. If you say your mentally ill, people instantly think in terms of insane asylums or movies like One Flew Over The Cuckoo’s Nest.

“Yes there are people who need to be hospitalised, but just because you’re mentally ill doesn’t mean you need that. Most people don’t. I thought that the more I ignored it and the more that I pretended that it had to be a secret, the more I was reinforcing the idea that it should be a secret. It made it something to be ashamed of, but the simple fact of the matter is that I have nothing to be ashamed of.

“The reaction from people has been great – my friends and family have been very understanding –  and a lot of my friends had been suggesting to me I needed help for a long time before I started to listen. I haven’t come across a negative response, although I am cognisant of the fact that maybe people have changed their opinion of me and just won’t say that to me directly.

“I’m sure there were people who saw my tweets and wrote me off there and then. Part of the reason for going public was that through exposure to me people would realise I’m actually normal.”

PANEL: Young people and depression

While stress and depression are widely understood amongst the adult population, there remains concern in the mental healthcare profession about attitudes to these issues amongst teenagers and young people.

The incidence of suicide is generally down, but suicide is still among the ten most common causes of death in Ireland and the principal cause of death in young adults, having increased four-fold in the past twenty years.

“As a society we tend not to take young people’s feelings seriously. When young people are growing up, there’s a lot going on in their lives. They’re developing physically, they’re maturing and they have very mixed-up feelings regarding who and what they are within society,” said Michele Kerrigan, chief executive officer of the mental health organisation Grow.

“Sometimes we can attribute all their problems down to just growing up, and in the process miss the signs that there is something deeper happening. They need a helping hand to get them over that hump. It’s like everything else — if you get help early, the recovery process is much quicker.  As people get deeper into depression, it becomes much harder to pull them out of it. It can be done, and people do it, but it’s much more difficult.”

According to Kerrigan, there are warning signs that parents can look out for to help them tell the difference between the normal ups and downs of adolescence and more serious signs of mental disturbance and illness.

“When you see someone withdrawing totally from their friends, then that’s a serious sign. Young people love to be around their friends so when they start pulling back from them and not wanting to go out, that’s usually a sign that something is wrong in their lives. Alongside this, it’s also important to look out for changes to sleeping and eating cycles – these indicate that something is on their mind,” she says.

“The internet is something else to keep an eye on. Through sites like Facebook and Bebo, kids can have other sets of friendships, whether real or not, and parents need to be careful about that. Teenagers can communicate in one way with their parents and family at home, and have a very different way of communicating online. They can in effect be two different people.”

Kerrigan points out that teenagers today are growing up in a world that takes technology for granted in a way that is usually alien to their parents.

“It’s a different way of communicating and because it’s not face to face it can be very harsh – it’s communication stripped of nuance and context. You’d be amazed, but people really do bare their souls on Facebook and Twitter, whereas if they were talking face to face with someone they’d probably be a bit more guarded.”

“In person, you can observe the other person’s body language, the tone of their voice and the look on their face, but all that nuance is lost on a computer screen. People feel free to say whatever they want without worrying if they are offending someone because they don’t see the reaction in person. That interaction can be pretty harsh for anyone, let alone teenagers.”

While bullying and abusive behaviour has always been a problem with younger people, the explosion in the use of technology amongst this age group has created new forms of bullying.

“Bullying is a huge issue for people, it can really affect their mental health and how they deal with other people. They can become very withdrawn and it can affect how they communicate with others, often right through school and into their adult and working lives. There are often sad stories in the media about young people who commit suicide as a result of bullying and harassment,” says Kerrigan.

“It’s really important to teach kids to have a base level of respect for their friends and other people. This is how they know how far they can go without pushing people too far. Somewhere in the middle of all this technology we’ve lost that piece of the puzzle.”

Grow recently launched a free book with the HSE aimed at reducing the stigma associated with mental health issues and suicidal thoughts in young people, entitled ‘You Can Do It – But You Can’t Do It Alone.’ Targeted at young people aged between 18 and 35 years, it’s available either on-line at http://www.grow.ie or in print from the HSE’s Health Promotion Unit at http://www.healthpromotion.ie

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