Depression in adults

Depression develops differently from person to person. In most cases, the illness develops gradually over a period of months, but the symptoms can also occur suddenly in the course of a few days or a week. Depression can occur at any age, in children, young people, adults and the elderly.

Approximately 25% of people who develop depression only experience one depressive illness in the course of their lives. The risk of new depressive episodes increases with the number of episodes the person has experienced. In 10–20% of cases the depression lasts more than two years. Residual symptoms often occur from several weeks to months after an episode of depression. These can include tiredness, lack of energy, problems sleeping or cognitive difficulties (problems with concentration, overview, initiative and memory).

Among people with recurring depression, many have completely symptom-free periods of various lengths, i.e. from weeks to years or decades. However, some will continue to experience depressive symptoms with varying degrees of severity and frequency between episodes.

Depression can progress in very different ways, depending on several factors. For example, the prognosis improves if the person receives appropriate and early treatment and there is good cooperation with the therapist. Factors such as emotional and mental resources and having a social support network also have a positive influence on the process.

The biological factors that may play a role in the development of depressive symptoms include hereditary (genetic) and hormonal factors.

Studies of families show that the risk of developing depression is three times higher (than for the population in general) in people with a parent or siblings suffering from depression.

As regards hormonal changes, pregnancy and childbirth are risk factors for depression. Metabolic disorders and illnesses involving under- or over-production of the adrenocortical hormone may also lead to depression.

Certain neurological diseases such as Parkinson’s disease, multiple sclerosis and strokes can also be accompanied by depression. Similarly, heart disease, arthritis and cancer can be risk factors.

Finally, the use of a wide range of medications and recreational drugs can lead to depression. These include corticosteroids, beta blockers (medication for heart disease and high blood pressure) or abuse of alcohol.

We also know that reduced exposure to sunlight can trigger depression in some people. The explanation for this is not just that circadian rhythms are supported by light (via, among other things, the neurotransmitter melatonin), but that light also affects the formation and release of the neurotransmitter serotonin.

Psychological and social factors can play a role in the development of depression. Early loss and neglect, bullying, harassment, as well as physical and sexual abuse during childhood can contribute to the development of a vulnerability which increases the risk of depression in adulthood. Social isolation, poverty and loneliness can also increase the risk of developing depression.

Some people have a personality that makes them more susceptible to developing depression. People who have low self-esteem or are very emotionally sensitive, perfectionistic or dependent on others may be at higher risk of developing depression.

Different types of stress as well as upsetting events such as losses, financial problems, loss of social status, unemployment, disappointments and conflicts can trigger depression.

Whether an exceptional event has occurred or exceptional circumstances lead to depression depends partly on the person’s own interpretation and handling of the situation.

Research indicates that psychological and social circumstances play the biggest role as triggering factors in the first depressive episodes. Several repeated depressive episodes appear in themselves to contribute to increasing sensitivity to the development of new episodes, so that in time less and less stress can trigger a new depressive illness

Feeling down

Your mood is not how you normally feel. You feel sad, cry easily, and feel an inner emptiness and hopelessness.

Lack of aspiration or interest

You lose the desire to do the things you normally enjoy doing. You lose interest in other people and activities and are unable to enjoy things normally associated with enjoyment. You may even find you are unable to feel anything at all.

Lack of energy and an increased feeling of tiredness

You feel tired, worn out and you do not feel like doing anything. Everything is a big effort. You often feel tired before the sadness takes hold, and the tiredness often continues after the other symptoms have passed.

Lack of self-confidence or poor self-image

You feel inadequate and you do not think you can cope. You have negative thoughts about yourself; for example, that you cannot do anything and you count for nothing. 

Self-reproach or feelings of guilt

You beat yourself up unreasonably, you feel you have done lots of things wrong, you feel you are a burden and turn everything against yourself.

Thoughts of death or suicide

Suicidal thoughts can often be present to various degrees, ranging from a feeling that it could be a relief not to wake up in the morning, to actually contemplating or even planning suicide.

Difficulty thinking or concentrating

You have difficulty collecting your thoughts; you are unable to concentrate and your memory is poor. You become perplexed and indecisive.

Agitation or inhibition

Agitation manifests itself in the inability to be at peace; you are fidgety and restless. Inhibition manifests itself when you move more slowly than normal or you sit rigid with little facial expression. In the worst cases of inhibition, you could be lying completely motionless, not eating or drinking anything.

Sleep disorders

You may have difficulty falling asleep, or perhaps you wake up many times during the night or very early. Many people wake up at four or five in the morning, their heads filled with depressing thoughts churning around incessantly. Everything seems utterly hopeless. Some people feel better in the afternoon; this is known as diurnal mood variation. Some people also feel a desire to sleep all the time, but no matter how much they sleep, they are still tired and out of sorts.

Changes in weight and appetite

You eat more or less than you usually do, and as a result, you put on weight or lose weight.

A number of other symptoms are often observed in addition to the above. In some cases, these symptoms can be so intense that the depression is overlooked:

• Varying degrees of anxiety. Anxiety can range from becoming anxious very easily to sustained anxiety. Sometimes, actual panic attacks can occur, and anxiety in social contexts is not uncommon. Anxiety about dying or about suffering from a serious physical ailment can also occur.
• Physical pain such as headaches, chest pain, back and stomach pain
• Aggressiveness, negativity and irritable behaviour
• Loss of libido

At least two core symptoms and two accompanying symptoms are present in mild depression. Generally speaking, the person suffering from depression is able to continue a normal everyday routine of work and leisure activities, but with reduced quality of life. Mild bouts of depression often pass naturally.

At least two core symptoms and four accompanying symptoms are present in moderate depression. The person suffering from depression often has difficulty functioning normally at work, as part of the family and in leisure activities. Moderate depression requires psychological or medical treatment.

In severe depression, all three core symptoms are present, together with at least five accompanying symptoms. The condition is extremely unpleasant for the depressed person and often leads to thoughts of suicide. In severe depression, there may sometimes be psychotic symptoms in the form of delusions or hallucinations.

Depression can bring on the delusion of being fully convinced that you are to blame for a serious accident or that the world and your loved ones would be better off without you. Hallucinations can include hearing voices saying negative things about you or encouraging you to commit suicide.

Depression is diagnosed on the basis of in-depth discussions and special interviews with the person in question. During the examination, emphasis is placed on the presence, degree of severity and duration of the individual symptoms.

The assessment takes account of what appears reasonable and appropriate in a given situation, and also takes account of the person’s usual condition.

It also explores whether the person has had any bouts of depression previously, and whether the person has any other psychological disorders such as anxiety, obsessions or compulsions. The person is also asked about any physical (somatic) disorders and symptoms.

The next of kin or other close individuals can often contribute valuable information in explaining the depression.

Diagnosis is important with a view to putting together the right treatment plan.

Many people suffering from depression also have other mental health problems. In particular, drug or alcohol abuse, anxiety, panic attacks, agoraphobia, OCD or social phobias frequently occur together with depression. Eating disorders, attention deficit or hyperactivity disorders (ADHD), behavioural disorders and autism-related disorders are also associated with an increased risk of depression.

If the person has other mental health problems in addition to depression, this will typically have a negative effect on the development of the depression. It can also make treatment more complicated.

Many people with depression also have lifestyle diseases such as cardiovascular disease. Moreover, a number of physical disorders increase the risk of developing depression, especially hormone-related diseases and neurological diseases.

Depression that occurs along with a physical illness is often overlooked. Conversely, a physical illness which is present along with depression may also be overlooked. It has been shown that depression occurring along with physical illness generally worsens the prognosis for the physical illness.

Emotional vulnerability

At the psychological level, depression is often associated with a number of temporary or long-term consequences that may themselves make the person more vulnerable to new depressive episodes. Common problems are lower self-esteem, reduced quality of life, loneliness and social isolation.

Some people with depression have felt particularly sensitive or vulnerable prior to their first depression. Others have previously felt and seen themselves as robust, but experience increased emotional vulnerability as a consequence of long-term or recurring depression. This vulnerability may manifest as an increased emotional dependence on others, a tendency to quickly activate negative thought patterns or to react strongly to experiences of rejection, criticism or disagreements.

Some people with depression also develop very inappropriate thought and reaction patterns in the form of brooding, worrying and stressful self-criticism.

Cognitive difficulties

Depression is often associated with cognitive difficulties. This means having trouble staying focused, remembering and keeping on top of things.

The person may find it very hard to make decisions or to plan, start and finish activities.

Some people with depression have had cognitive problems, such as problems staying focused and keeping on top of things, prior to their first episode of depression. This is the case, for example, with people who have attention disorders.

While some people mainly have cognitive difficulties during the depressive episode itself, others also experience a significant impact on cognitive functions for a long time after going through depression. While most gradually return to their normal cognitive functions, some continue to have major difficulties with attention, memory and keeping on top of things.

In some cases the cognitive difficulties worsen with the number of depressive episodes. Lasting cognitive difficulties are in themselves associated with increased vulnerability to stress and strain and are a significant factor in susceptibility to new depressive episodes.

Problems with attention, memory and maintaining an overview can easily give rise to self-criticism and feelings of shame at not living up to the person’s own and others’ expectations of what they should be able to do at home, in their spare time, in their studies or in the workplace. Both the person and the people around them may mistakenly interpret these cognitive problems as a sign of stupidity, laziness or lack of commitment and willingness.

There are different forms of treatment that can have a positive effect on depression or help prevent new depressive episodes. In severe depression and some cases of moderate depression, medication can play a crucial role. However, medication should be combined with different types of talking therapy.

Before treatment is started, the person will have a consultation with the therapist to discuss the most appropriate forms of treatment.

Consultations with your contact and contact doctor are a very important part of your treatment – regardless of whether you have been admitted to hospital or are receiving outpatient treatment.  If you are suffering from severe depression, the consultations will be of a supportive nature and be based on current situations.

When your depression begins to ease and your concentration and memory improve, other topics can be included. For example, you and your doctor can examine the possible causes of your depression, discuss the course of your illness in depth and make plans for the near future. Identifying what triggered your depression may help you avoid recurrence in the future.

You – and your relatives – will be offered education about relevant aspects of depression and how to deal with it.  It is important to know as much as possible to enable you to cope with your depression and, if possible, prevent recurrence.

The psychoeducation may be conducted in groups or individually.

Depression may lead to inappropriate thought and behavioural patterns. This may be related to various psychological issues, such as loss, trauma and personal circumstances. These issues may contribute to maintaining depression or triggering new depressive episodes.

Psychotherapists typically work with some of the factors that can contribute to triggering or maintaining depression. These consultations may be conducted individually, in groups, with couples or families. The purpose of the therapy is to reduce your symptoms of depression, prevent suicide, prevent new depressive episodes and improve your ability to function in your everyday life.

Whether you can benefit from psychotherapy depends on a number of factors, including your current condition (such as the severity of your depression), your medical history and motivation.

There are various therapeutic methods that are effective in treatment of depression, for example cognitive behavioural therapy, interpersonal therapy or psychodynamic short-term therapy.  The individual psychotherapeutic course varies in relation to content, objective, methods and duration, but the relationship between you and your therapist is always of great importance.

As a rule, medication is recommended for treatment of severe depression. In certain cases, it is also used to treat moderate depression.

Anti-depressants act on some of the chemical processes that are out of balance in the brain in connection with depression. For example, the medication normalises the level of the stress hormone cortisol and the brain’s neurotransmitters serotonin and noradrenaline. They are of importance to mood, concentration and memory. In addition, a normal level of these substances is also important for you to have a normal daily rhythm and sleep-wake cycle.

It can take up to 4–6 weeks to establish whether the medicine is working. Sometimes the dose needs to be increased, or it is necessary to try a new medicinal product, if the desired effect is not achieved or if you experience unpleasant side effects. A number of elements are taken into consideration in the preparation of your treatment plan such as your age, the severity of your depression and the number of previous depressive episodes.

ECT is an extremely effective treatment for severe bouts of depression where there is an imminent danger to life either due to the risk of suicide or because the depressed person has stopped eating and drinking. This treatment is also used if other treatments have proved ineffective.

The treatment involves the person having an electric current directed at parts of the brain, under anaesthetic, via two electrodes placed on the head. Various studies indicate that therapy using ECT also stimulates the formation of new brain cells. To prevent recurrence, the treatment is usually supplemented with medical treatment and, in some cases, preventive ECT therapy is used.

There is a high risk of bouts of depression recurring later in life – especially in someone who has already suffered more than one bout of depression. This is why it is important to prevent further depressive periods.

Prevention is part of the treatment, but there are things you can do yourself to reduce the risk of recurrence.

Some of the key areas of preventive work are described here.

Be aware of pressures and early warning signs

It is important to talk through the course of depression in depth in order to be able to put it behind you and so that you can learn from it. If pressures contributed to triggering the depression, it might be possible to avoid putting yourself into similar pressurised situations in future, or you could learn new ways of handling pressure.

If you are able to identify the symptoms that manifested themselves as the first indications, that will make it easier to seek help in time. Early signs of depression may include starting to wake up early, having a lot of negative thoughts and having difficulty remembering things. You can get help to chart the early warning signs, trigger situations and appropriate strategies by talking with your GP, a nurse or a psychologist.

Involve your loved ones

Your loved ones play a key role in preventive work. They can participate in discussions while you are having treatment. They can also familiarise themselves with the illness, its course and treatment, as well as how best to relate to the various phases of its course.

Those closest to the person suffering from depression can contribute important information. They usually know the depressed person extremely well. Relatives are often the first to notice changes in behaviour at the onset of depression or to become aware of any pressures the person is under.

If a renewed bout of depression is on the way, they can support the depressed person by responding appropriately and seeking professional help.

Medicine

Medical treatment can help reduce the risk of recurring bouts of depression. It is common to consider stopping taking the medicine when the person is feeling better.

However, it is important for the depressed person to follow the doctor’s orders as regards the dose and the duration of the treatment. If there are any unpleasant side-effects, a solution should be sought in consultation with the GP.

It is generally advisable to continue with medical treatment for at least six months to a year after coming out of the first bout of depression.

Recommendations about the duration of treatment depend on factors such as the number of previous bouts of depression. Some people require treatment for many years, and others need life-long treatment.

• Learn to recognise your illness. Be well informed so that you will be better able to handle your illness.
• Comply with medical treatment. Do not stop taking your medicine of your own accord until you have discussed this with your GP.
• Make use of your GP, nurse or psychologist.
• Talk to your loved ones about the things that can prove difficult because of your illness.
• Avoid extensive use of alcohol, as well as sleeping medicine and anti-anxiety medication. This could increase the risk of another bout of depression.
• Get some exercise. This can help to divert your sad thoughts and reduce the stress and unpleasantness.
• Demand less of yourself. You will be more tired, and you will have less energy and capacity for a while after a bout of depression.
• Be sure to plan your day. Use a calendar or diary. Remember to plan nurturing activities.
• Be open about your illness, when appropriate.
• Make sure you sleep well and have a healthy diet.
• Practise challenging negative thoughts.
• Include breaks in your everyday routine. Resting can reduce your stress level.
• If you have difficulty paying attention and remembering things, you should take this into account. For example, you could write things down and make other people aware of your difficulties.
• Allow yourself to fail. Everyone makes mistakes.
• Talk to other people who have suffered from depression.

It can be a challenging experience being close to someone who suffers from depression. This produces a variety of emotions. Sadness, uncertainty, irritation, frustration and anxiety are common responses among loved ones.

They are often deeply affected by watching the suffering of someone close to them. Many feel powerless because there is nothing they can do directly to bring the suffering to an end.

Some relatives can become tired and worn out. They may have to take on more practical tasks than usual. They want to support the sick person, while still holding down their own job, education or other activities.

If you need to give long-term support to someone who suffers from depression, you will also need to take care of your own needs and try to lead as normal a life as possible. You must try to accept that you will not always be in a condition to provide help. No one can be present, positive and available all the time. You may need to take a short or longer break at times.

It helps if you can share the responsibility with other relatives so that you do not have to bear the brunt of the responsibility yourself. In addition to having contact with therapists, you might also benefit from contacting patient and carers’ associations such as SIND’s Pårørenderådgivning (advice for relatives), Bedre Psykiatri (“better psychiatry”) or Depressionsforeningen (association for depression), all of which provide advice over the telephone.

If you personally feel you are becoming emotionally overburdened as time goes on and/or you are developing distinct symptoms of anxiety or depression yourself, you should consult your own GP to get help and support. In some cases, a referral to a practising psychologist will be possible with a subsidy from health insurance.

When the person suffering from depression has children, special attention should be paid to their needs and reactions. It is important to talk to the child about the parent’s illness. It is possible to have family counselling at the treatment centre, and some municipalities have facilities for the child to participate in a children’s group with other children whose parents suffer from depression.

As a relative of someone with depression, it is a good idea to find out about the illness, key symptoms and treatment. If you feel able to offer support to the depressed person, you could find out what they need during the different phases of the process. Family counselling with a counsellor might prove helpful in this regard.

In an emergency, e.g. in the case of severe depression, where the person experiences the urge to commit suicide, you can help by establishing contact with the GP, emergency doctor or a psychiatric emergency ward. If the sick person is already undergoing treatment and agrees to it, the treatment centre can be your first port of call if the person’s condition deteriorates seriously.

If you are in any doubt about how best to support someone with depression, you can ask the person directly. You can offer contact, but there is a great deal of variation in what a depressed person needs or is able to cope with. While some people in depression want to talk about how they feel, others prefer to be distracted, e.g. by talking about things entirely unrelated to the illness.

The depressed person should be given support to maintain hope that he or she will get better and to keep going at his or her own pace. Recognition of the person’s efforts is key. Very ordinary tasks, such as having a bath or getting up, require a great deal of effort on the part of a person with severe depression. In some cases, you may need to relieve the sick person of all responsibilities. In other cases, it works better if you tackle tasks together rather than you, the relative, simply taking over tasks and functions.

If you are worried that the person with depression is contemplating suicide, you should try to talk to him or her about it. Perhaps you can help him or her to recognise other solutions; above all, it is important not to be condemnatory towards the person. If the urge to commit suicide is strong, the person should not be left alone.

After a bout of depression, the person is usually more tired and vulnerable. The ability to be attentive, to remember things and to keep track of things is often impaired. As a relative, there are various ways you can offer support. You can help by organising the person’s everyday routine and maintaining a stable rhythm. You might need to repeat important information and messages, or write things down. You could also check whether the person needs support to plan, start and complete specific tasks, such as housework, shopping, gardening and leisure activities. If it is not possible for the person to return to his or her former level of functioning at first, you must try to adjust your expectations, even though this may be difficult.