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Session Two - What can I do when my
family member is depressed?



Materials Needed: Handout E: "What Can I Do When My Family Member Is Depressed?"
Video: When You Love Someone Who Is Depressed: Depression and its Impact on Marriage and the Family

Brochures on local treatment options for patients with depression

  1. Symptoms of depression

    1. Depression can manifest itself in many different ways. All human beings feel depressed or down at times; however, the disorder of Major Depression is more than just feeling the "blues" every once in a while.

            Discussion Questions:

      • What are some symptoms of depression?
      • Which are most difficult for you to cope with?

      1. Feeling sad, blue, or down
      2. Loss of interest in previously enjoyed activities
      3. Change in appetite or weight
      4. Change in sleep patterns
      5. Feeling tired and fatigued OR feeling restless
      6. Feeling worthless or guilty
      7. Trouble concentrating, thinking, or making decisions
      8. Thoughts of death or suicide

    2. The diagnosis of a major depressive episode is made when a person experiences 5 or more of these symptoms that occur nearly every day for at least 2 weeks – with at least one symptom being depressed mood or loss of pleasure in previously enjoyed activities ( DSM-IV ).



    3. Approximately 6.6% of the nation (13-14 million people) suffer from some type of depression every year (Kessler, Berglund, Demler et al., 2003). It is often called the “common cold” of mental illness. Many famous people have struggled with clinical depression, including television reporter, Mike Wallace; British prime minister, Sir Winston Churchill; Pulitzer-Prize winning newspaper columnist Art Buchwald; and Academy-Award winning actor, Rod Steiger.

      .

    4. According to a large community study, the prevalence of major depression in adults is approximately 16%, making it one of the most common psychological disorders. The average duration of an episode is 16 months (Kessler et. al., 2003).



    5. Women who have had at least one episode of depression outnumber men by a ratio of 1.7 to 1. Also, people living in poverty are approximately 4 times more likely to suffer from chronic depression than more affluent people (Kessler et al., 2003).

    6. Depression also tends to be recurrent, as about 80% of individuals with depression experience another episode within one year (Coryell et al., 1994).

    7. Oftentimes an individual with major depression also has another psychiatric disorder. For example, one large study found that almost ¾ of people with major depressive disorder also met criteria for another disorder (commonly anxiety disorders and substance use disorders) (Kessler et al., 2003).

    8. Due to the very nature of depression (decreased concentration, decreased motivation, social withdrawal, fatigue, etc.), individuals are often less productive in the workforce. In fact, US workers with depression cost employers approximately $44 billion per year in lost productive time (Stewart et al., 2003). Depression has been described as the leading cause of disability.



    9. Show and discuss video:
      • When You Love Someone Who Is Depressed: Depression and its Impact on Marriage and the Family. (University of Notre Dame Alumni Association, 1998)

  2. What causes depression?

    1. No one single factor causes depression. Oftentimes doctors cannot determine the specific cause of a patient's illness. The constellation of causes is unique to each individual.

    2. Family members and friends need to remember that depression is not the person's fault.

    3. Several causes are common:

      1. Certain life events may trigger a depressive episode (e.g., death of loved one, retirement).
      2. A strong genetic factor is present in many cases of depression.
        • If one identical twin has major depression, the other twin has an approximately 50% chance of developing depressive symptoms sometime in his/her life.
        • If one identical twin has manic-depression, the other twin has a 70% chance of developing the disorder (Carter & Golant, 1999).

      3. Depression may be caused by an imbalance in the level of chemicals in the brain. Many antidepressants work by regulating the levels of these chemicals (neurotransmitters).
      4. Medical illness may be a causative factor in depression.
      5. Use of certain medications may cause depressive symptoms (e.g., some anticonvulsants or thyroid hormones).
      6. Excessive use of alcohol and other drugs may contribute to depression, as alcohol acts as a depressant on the central nervous system. Further, substance abuse complicates the diagnosis and treatment of the underlying psychiatric disorder(s).


  3. The impact of depression on relationships

          Discussion Questions:

    • How has your loved one's depression affected your relationship?
    • Your family life?
    • Your view of yourself?

    1. Depression affects the person's behavior and style of communication (less eye contact, slower and softer speech, negative thinking, reduced problem solving abilities).

    2. Depression is often accompanied by an increase in marital tension and arguments.

    3. Depressed people have greater difficulty interacting with others. Therefore, the social life of the couple / family may be altered.

    4. Some depressed people are unable to work. Therefore, other family members may have to get a job for the first time or work two jobs to compensate for the reduced income.

    5. Family members often become frustrated with the depressed person's behavior, thinking the patient should just "get over it" or "cheer up."

    6. Depressed people often have decreased interest in physical intimacy and sexual activity. Partners often worry that the patient is no longer physically attracted to them, which can increase the tension in the relationship.

  4. Important issues surrounding suicide (parts adapted from Woolis, 1992)

    FACILITATOR NOTE: As these issues may be difficult to discuss, the facilitator may wish to normalize any anxiety when talking about these issues. Coping skills will be addressed in the next section.

    1. Many family members worry a great deal that their loved ones may try to kill themselves.

      1. Individuals with mental illness do commit suicide at a rate that is 12 times higher than the general population.
      2. Over 90% of suicides are associated with a mental disorder (Clark & Fawcett, 1992).
      3. More specifically, one-third of all clinically depressed patients attempt suicide, and approximately 15,000 people with mood disorders kill themselves each year (Adamec, 1996).
      4. One in every 10 young men with schizophrenia commit suicide (McGuire, 2000).
      5. Men are 4 to 5 times more likely to complete suicide than women. Women are 3 times more likely to attempt (but not complete) suicide than men (Moscicki, 1995).


    2. Many reasons exist for why people consider and attempt suicide:

      1. Some make a decision to end their lives - they are very unhappy with their lives and feel hopeless that the situation will improve.
      2. Some engage in reckless behavior because they don't think they will die (e.g., jump off a tall building believing they are super-human). Their judgment is impaired, and they may not understand the consequences of their behavior.
      3. Some hear voices telling them to harm themselves.
      4. Some do not know how to ask for help more directly, but kill themselves unintentionally (e.g., take too much pain medicine; cut wrists, etc.)


    3. Red flags that warrant further exploration:

      1. Changes in the level of depression (more depressed or happier than usual), especially if he/she:
        1. Has a specific plan for how they would kill themselves
        2. Has access to lethal means (such as weapons, pills, etc.)
        3. Feels worthless
        4. Talks about having done an unforgivable behavior
        5. Feels hopeless about the future
        6. Hears voices telling them to harm themselves
        7. Begins to get their affairs in order (e.g., writes a will, gives things away, systematically contacts old friends or relatives)
        8. Has experienced a recent significant loss (or perceived loss)
        9. Lives with chronic medical illness and/or chronic pain

      2. Has previously attempted suicide OR has a history of being impulsive
      3. Talks about killing him/herself (e.g., "everyone would be better off without me")
      4. Makes suicidal gestures (takes too many pills, cuts wrists, etc.)
      5. Talks about being indestructible or having supernatural powers during a manic or delusional state
      6. Increases use of alcohol or other drugs. These substances may increase the level of depression AND may lower inhibitions, both of which are dangerous with suicidal patients.

    4. What do I do if my family member is suicidal?

            Discussion Questions:

      • What have you found to be helpful for yourself and for your loved one when he/she shares thoughts of suicide?
      • How do you feel in these situations?

      1. TALK ABOUT IT! Asking about suicide will NOT put ideas in the patient's head and will not make the situation worse. Your family member may even feel relieved to be able to talk about it.

        • Discussing suicidal ideation can be very important, as 50-70% of people who complete suicide communicate their intent in advance, usually to a family member (Adamec, 1996).

      2. Offer emotional support by:

        1. LISTENING in a nonjudgmental, compassionate manner
        2. Empathizing with their feelings (e.g., "it must be awful to feel that way")
        3. Reminding them of recent accomplishments
        4. Normalizing depression and thoughts of suicide
        5. Expressing your concern, care, and willingness to help

      3. Ask if they have a plan about how they are thinking about killing themselves. If they describe a specific plan, then:

        1. Seek professional help immediately
        2. Try to get them to make an agreement with you that they will not act on these plans without first talking to you, a hotline, or a mental health professional
        3. Put away any objects that they may use to harm themselves (guns, knives, pills, razors, etc)

      4. If the person is delusional (expressing false beliefs), seek professional help.

      5. If you don't know what to do, call a professional (e.g., suicide hotline, mental health professional, police)

        • National SUICIDE Hotline: 1-800-SUICIDE
        • Suicide hotline in Oklahoma City: (405) 848-CARE


      6. Sometimes suicide happens without warning and nothing can prevent it from occurring.

      7. Even with warning signs, there still may be nothing you can do.

      8. Family members can benefit from discussing this issue with their loved ones when they are not actively suicidal. Together, the caregiver and patient can create a plan for how to cope with this inherently stressful situation if it arises again in the future (Spaniol & Zipple, 1994).

      9. Consider seeking professional help for yourself. Caregivers often experience intense anxiety, worry and feelings of powerlessness when patients make suicidal threats (Jones, Roth & Jones, 1995).

  5. Provide local treatment options for individuals struggling with depression

    Example: Oklahoma City VA Medical Center


    1. Depression Management Class
      •   This 8-session class consists of three modules addressing issues of: increasing pleasant activities, modifying dysfunctional thought patterns, and improving interpersonal skills.



    2. Day Treatment Center
      • The Day Treatment Center provides a structured intensive program for veterans experiencing chronic mental illness (including depression).

    3. Anti-depressant Medications
      • The patient's primary care provider can prescribe many anti-depressant medications. In addition, psychiatrists in the mental health units have special training in prescribing and monitoring psychiatric medications.

         

        Antidepressant medications are not habit forming, so patients do not have to worry about becoming addicted to the drug.

         

        Antidepressants are quite effective. Most studies demonstrate at least a 50% decrease in symptoms for approximately 70% of patients (Tamminga et al., 2002).



    4. Electroconvulsive Therapy (ECT)
      • Electroconvulsive Therapy (ECT), also known as shock treatment, is a safe and painless (yet rather controversial) treatment option for patients with severe depression who do not improve with medications. The success rate of ECT (80-90%) is higher than that with antidepressants (approximately 70%). ECT is administered by deliberately inducing a seizure, and the potential adverse effects of this procedure (e.g., confusion and memory loss) must be considered (Tomb, 1995).
      • The patient should discuss this option with his/her psychiatrist if interested in this treatment.

  6. Coping strategies for the family

    1. DO's

      1. Acknowledge that clinical depression is a legitimate illness. Learn about depression and its impact on the family.

        Some Good Books on Depression:
        What to do when someone you love is depressed. (1996). M. & S. Golant.
        Overcoming depression. (1987). D. & J. Papolos.
        When someone you love is depressed. (1996). L. Rosen & X. Amador.
        Sherman, M.D., & Sherman, D.M. (2006). I’m not alone: A teen’s guide to living with a parent who has a mental illness. Edina, MN: Beaver’s Pond Press. Available at www.seedsofhopebooks.com

        Interesting Movies on Depression:
        Ordinary People
        Patch Adams

        Relevant Web Sites:

        www.depression.com comprehensive resources about depression

        www.depressionfallout.com help for those dealing with depressed loved one

        www.depressionoptions.com depression and sexual functioning

        www.intimacyanddepression.com examines effects of depression on relationships

        www.nimh.nih.gov/publicat/depression.cfm National Institute of Mental Health

        www.dmda.org Depression and Bipolar Disorder Alliance

        www.familyaware.org Families for Depression Awareness



      2. Have realistic expectations (e.g., depression cannot go away overnight)…but also maintain hope.
        1. New antidepressants and treatment strategies are being studied and released on the market. Many patients with depression are able to lead constructive lives.
        2. For example, the movie Patch Adams starring Robin Williams depicts a young man admitted to a psychiatric unit due to major depression and suicidal ideation who later becomes a successful physician.

      3. Be an active team member in the care of your loved one. Ask questions of doctors, nurses, psychologists, and other health care providers.
      4. Offer emotional support, patience, and compassion. Encourage your loved one to exercise and do activities that he/she used to enjoy. Allow your loved ones to care for themselves as much as possible.
      5. Stay in contact with your social support network.
      6. Obtain professional help for yourself when needed.
      7. Maintain good sleep habits, both for you and your loved one (e.g., go to bed and get up at the same time every day; reduce caffeine intake).
      8. Make healthy lifestyle choices (healthy diet; regular exercise; avoid use of alcohol).


    2. DON'Ts

      1. Try not to take the depression personally - it's not your fault! You cannot cure depression with love any more than you can cure cancer with love.
      2. Don't exclude the depressed person from family discussions or decisions.
      3. Don't try to do everything for the depressed person.
      4. Don't criticize the person for their depressed behavior or expect him/her to be able to simply "snap out of it."
      5. Don't feel that you need to apologize for your loved one.
Special thanks to Lisa Swisher, Ph.D. who contributed to this session outline.