Last partial update: January 2018 - Please read disclaimer before proceeding.

Depression in Australia

Depression is the most common mental illness in Australia, with 3.4 per cent of males and 6.8 per cent of females reporting the condition in 1997. About 20 per cent of the population will suffer a significant bout of depression at least once in their lives. It is also the fourth most common reason for GP consultations. Significantly, depression does not just affect the sufferer. Their whole family is usually intimately involved and the whole family’s quality of life suffers considerably, especially if the condition remains unrecognized or is ignored for a long period as is often the case. It is an illness that is on the increase and will be one of the major health problems of this century.

Depresion Adult Incidence grapth1

Source – Adapted from Australian Institiute of Health and Welfare: Mathers 1999.

While it is more prevalent in females, the figure below shows that when the burden of disease from suicide and depression are added together, males actually suffer more from these conditions. Depression is a disease that usually starts in young adults and adolescents and for this reason it is important that prevention strategies target this group and younger children.

A major concern surrounding this disease is that only about 50 per cent of people with depression are diagnosed and receive treatment. This is especially a problem in the elderly and is due to both non-presentation and missed diagnosis. Those that are diagnosed are not uncommonly under-treated or not followed up with respect to identifying recurrence of symptoms; a common event.

In adults, episodes of depression typically last about six months, although they are often considerably longer in the elderly. There is a 50 per cent chance of recurrence after an initial episode and a 90 per cent recurrence rate after a third episode. Overall, it is likely that most Australians will be closely affected by depression, either directly or through a family member or close friend, at some stage during their lives.

Very importantly, up to 15 percent of significantly depressed people end up committing suicide and for this reason it is imperative that great care is taken when a person is suffering a significant depressive episode. This is especially a problem in men. Over three percent of all male deaths in 1996 were from suicide.

The boundary between depression and anxiety is often unclear and it is very common for people to have symptoms of both conditions at the same time. (Their causes and treatments are similar.)

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What causes depression?

Psychological, biological and environmental factors can all cause depression and any combination of these can be present in one person. Psychological causes relate primarily to early life experiences, inappropriate parenting and learned negative thoughts. Some personality traits that are more common in depressed people include shyness, perfectionism, chronic worrying, unassertiveness, self criticism, anxiety in social situations and low self-esteem.

Environmental factors relate to causes of significant stress, including relationship problems, work related stress (or job loss), emotional / physical abuse, bereavement and traumatic events. (Forced sexual abuse is more common in women and may partially explain their higher incidence of depression.) In general, long standing problems such as chronic relationship problems tend to be more important than recent stressful events.

The prime biological factor is genetic predisposition and this is a major cause in around 40 per cent of depressed people. Depression often runs in families. Other biological causes include chronic illness, hormonal changes and some medications. Biological factors (and quite probably many psychological and environmental factors) cause depression by altering chemicals in the brain as follows;

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Prevention of depression – Some successful strategies to use.

Most people with depression develop their problem during childhood, usually as a result of childhood anxiety problems. As with the prevention of adult anxiety, the prevention of adult depression really requires the development of good coping skills during childhood. Parents can help their children accomplish this by ensuring that they practice good parenting techniques and ensuring that their child’s school has programs to improve self-esteem. This aspect of prevention is dealt with in full in the boxed section Preventing childhood depression that appears below.

Depression varies greatly in its severity and its diagnosis for this reason is not always clear cut. There is no ‘yes or no’ blood test!! There will always be a large number of people who are borderline depressed, either temporarily or for much of their lives; the so called half ‘glass half-empty’ people. Some of these people will at times meet the criteria described below for depression and if this occurs they need to receive treatment. However, there are several techniques that this group of people can adopt to reduce their chances of developing depression and indeed improve their overall outlook towards and enjoyment of life.

1.   Incorporate ‘event scheduling’ into everyday life

Many people who are depressed or close to it reduce the number and type of activities they do and this unfortunately includes their pleasurable activities as well as ones that are less so. Thus, they enjoy life less. Another unfortunate consequence is that they have reduced contact with other people, seeing old friends less and making fewer new friends, and this reduces the likelihood that they will be included in the social activities of these people.

One way of reducing this problem is to actively incorporate ‘event scheduling’ into daily life. These can be any sort of events; they do not need to be major occasions that cause stress. Events that involve repeated regular involvement are best. Local councils often have lists of clubs / activities. Often a good way to start is to reestablish contact with long-standing friends or resume past interests that are not presently being pursued. Some examples of the range of activities available and strategies that cab be pursued include:

While some activities can be done on the spur of the moment, much ‘event scheduling’ requires planning. Bookings may need to be made etc so be sure to think a bit ahead. (This is why focusing on recurring events, such as weekly sporting commitments, is especially helpful.) A good strategy is to do event scheduling at least three weeks ahead, especially when it involves other people, and to set aside a particular time of the week for doing this organising.

One of the problems in being ‘down’ is that the sufferer does not recognise that they are reducing their activities, and even when they do, they find it difficult to get the motivation to change. An important part of living is to be aware of the important people in ‘life’; relatives and friends. Look for the signs that that a friend / partner is down at the moment. Help them with any problem that might be causing these feelings and make sure they are included in regular activities where possible.

Finally, it is common for people who have a tendency to be ‘down’ much of the time to use alcohol excessively and to become dependant on alcohol. For this reason, try to make sure that activities do not focus excessively on alcohol consumption and if alcohol is a known problem for the person involved, try finding activities that do not involve drinking at all.

2.   Become more physically active

There is strong evidence that regular physical activity improves depression and it can also help reduce the risk of developing depression. Such activities are of great benefit whether done alone or with other people, although doing activities with others helps socialization and increases the likelihood of increased other social contact. Aspects of increasing physical activity are covered in full in the chapter on this topic that appears later in this book.

3.   Improve ‘thinking’ about problems

Many people have learned unhelpful ways of dealing with problems that make them unnecessarily unhappy. This often has to do with automatically thinking negatively when faced with everyday problems and thus often worrying unnecessarily. Learning to both identify when such thinking is inappropriate and attempting to adopt a more constructive and helpful response in such circumstances is often very beneficial. (This is the basis of Cognitive Behavioural therapy. It is used to treat depression but is useful for everyone to adopt into their lives. This topic is discussed more fully in the section on Achieving Change and should be read!!)

4.   Refraining from alcohol and illicit drug abuse

Alcohol and illicit drug abuse are well-established risk factors for developing depression. Everyone needs to be very careful regarding that they minimize their harm from drug use and people who are at increased risk of any mental illness should consider not using them at all. It is always worth assessing personal alcohol use regularly. (See section on alcohol.)

5.   Getting adequate sleep.

People who are chronically tired due to problems sleeping or devoting insufficient time to sleep are more likely to develop depression. This can be especially a problem for parents with young children. Friends and grandparents can be a great help here. Further information on this topic is provided in the section on sleep.

Adopting the above strategies is a great way for everyone to stay mentally well and will be beneficial to all those who incorporate them into their lives. They will not, however, prevent depression in some people and are certainly are not a substitute for the treatment of clinically depressed people, although they are all part of such treatment.

6. Eating a healthy diet

There is increasing evidence that depression is execcerbated by poor diet and that improving diet can help with both the prevention and treatment of depression. (Click here for information about healthy eating.)

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Prevention of depression during pregnancy and postnatally

Prevention of depression in pregnancy relies on maximising family support and providing time for relaxation, especially if this is not the first child. Sleep deprivation and over–working need to be avoided as well. These initiatives are especially important in women at risk of depression. Factors increasing this risk are mentioned in the section on identifying depression in pregnancy. (See below).

Screening people for depression
While there are numerous screening tools available for diagnosing depression, there are no guidelines (yet) stating who should be screened. However, many medical practitioners consider it wise to screen people at increased risk. These include:

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Diagnosis of depression in adults

There are numerous screening tools for diagnosing depression with the following being one of the most commonly used. It states that depression is diagnosed when at least five of the following nine symptoms, including at least one of the first two symptoms, are present for at least two weeks.

  1. Depressed mood, sadness or felt miserable for most of the day.
  2. Loss of interest or pleasure in all or most usual activities for most of the day. (Withdrawal from friends, family and previously enjoyed activities.)

Substance abuse and medical conditions, such as hypothyroidism and brain injury / disease (e.g. stroke, epilepsy or Parkinson’s disease) can cause similar symptoms and need to be excluded as causes of the above by a doctor, as does recent bereavement.)

The criteria for diagnosing depression in the elderly are slightly different and are detailed in the boxed section on depression in older people below.

It is important to recognise that assessing such symptoms is how doctors, psychologists and other health workers diagnose depression when seeing patients. Patients and relatives need not and indeed should not keep to such rigid definitions as they are not trained in making such diagnostic decisions. The message for them is that such lists of symptoms are only a guide and if people are concerned about themselves or a friend or relative they should always seek help. Some signs to look for include an increase in any of the following; alcohol and drug use, social withdrawal, irritability or moodiness and time missed from school or work, staying awake through the night, unnecessary risk taking and loss of interest in pleasurable activities such as food, sex or exercise.

Grief following a significant life event can sometimes appear like depression. However, grief reactions are usually short-lived with reduced functioning usually returning relatively quickly. The person also does not usually experience feelings of hopelessness or thoughts of ones own death. Of course, unresolved grief can lead to depression.

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Recognising depression in women

Pregnancy - Perinatal depression (PND)

Depression is a well-recognized problem after delivery with 10 to 15 per cent of new mothers becoming depressed in the year following the birth of their child. (Post-natal depression (PND) needs to be distinguished from a transient depression of mood that occurs in the first week after delivery in about 70 per cent of new mothers.) As with other types of depression, anxiety episodes commonly occcur at this time.

Recent research has shown that depression is at least as common during pregnancy (antenatal depression) and all people need to be aware of this problem so that they can help recognize symptoms in friends, relatives or themselves, especially if risk factors for depression are present. The incidence is lower in the first trimester, with an incidence of about 7%. The incidence in the second and third trimester is about 12%.

It is also important to realise that perinatal depression often does not resolvewith time after childbirth and that many women who suffer from the condition have long term problems with depression. Interestingly, recent research has found that most of the women who had problems with perinatal depresssion had a history of depressive symptoms often going back to their late teens.

Recognising perinatal depression (PND) is important as the condition is associated with numerous problems that be avoided with adequate treatment. These problems include the risk of developing chronic depression, harm to the baby / other children and long term affects on the womans relationships with her partner, family and friends.

The risk factors for PND include:

Prevention of PND relies on maximising family support and providing time for relaxation, especially if this is not the first child. Sleep deprivation and over–working need to be avoided as well. Fathers and grandparents can be a great help here.

It is thought that only about 50 per cent of women with PND are diagnosed and treated. For this reason, programs aimed at identifying women who are at risk of or who have post-partum depression are now commonly used introduced in Australia and should be part of both every woman's antenatal and postnatal care.

A wealth of good information about PND and other issues faced by new parents can be found on the Beyond Blue web site where women can access the Edinburgh Postnatal Depression Scale to assess whether they have developed significant depression.

https://healthyfamilies.beyondblue.org.au/pregnancy-and-new-parents

Any woman who has thoughts of suicide or harming a baby or other children needs urgent (same day) specialist mental health assessment.

Physical trauma occuring with childbirth

Child birth is not uncommonly a traumatic time for women. Things do not go as expected; caesarians are needed, excessive bleedding occurs, disability results from damage to pelvic floor muscles / urinary problems and anal sphincter tears. These issues left unresolved / untreated can cause significant upset and women often are reluctant or are not given adequate opportunity to address them. A good time to address them is the six week check up and making sure that a long appointment is made at this time is important. (Obviously some issues need to be addressed well before this time.) Advice regarding these issues is available from the Australian Birth Trauma Association at: www.birthtrauma.org.au

Harm to others

It is important to note that the new baby and other children in the family may at times be at risk when the mother has PND. Harm to other children can occur by neglect or by physical / mental abuse and either parent / partner may be involved. If this is occurring or if there is a risk that it will occur, a medical practitioner or appropriate child protection authorities need to be notified without delay. Harm to the unborn foetus is also more likely where depression occurs with the pregnancy. This includes harm from alcohol / other drug misuse by the mother or by a mother’s general disinterest in her own personal health / care.

Also see section on Maternal sleep deprivation after childbirth

Depression in perimenopausal period

Depression is very common in the perimenopausal age group and suicide in women is most common in the 50 to 54 year age group. It is important that depression symptoms looked for and treated in this age group and are not thought of as temporary / a normal part of menopause.

 

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Depression in older people

Depression is not uncommon in old age but it is not a normal part of ageing. While reasons for sadness, including illness and personal loss, are more common in older people, they do not usually bring on depression. However, the fact that many people do' expect' symptoms such as sadness and loss of interest in and enjoyment of life in the aged explains why these symptoms often go unreported and why depression is often missed in this age group.

Depression in the elderly is often a chronic condition with only about 25% remitting after six months. It also often presents as low grade chronic condition rather than an acute major depressive episode. (Older people with depression may thus haver fewer depressive symptoms than people presenting with a more acute illness.)

The consequences of untreated depression in the elderly include:

  • difficulty coping with physical illness
  • overuse of medical services,medications and social services.
  • alcohol misuse and misuse of medications such as benzodiazepines (sleeping tablets)
  • loss of functional roles in family / society
  • alienation of family and friends
  • premature retirement
  • malnutrition and reduced self-care
  • premature death (including suicide)

Diagnosis - Depression should be considered in an older person where the person has the following:

1. For more than two weeks has either felt sad and miserable most of the time OR has lost interest in most of their activities for a similar period

AND

2. Has experienced symptoms in at least three of the following categories:

    • Altered behaviours: including a general slowing down or restlessness; withdrawal from family and friends; decline in day-to-day functioning (i.e. loss of interest in self care and normal responsibilities) with confusion, worry and agitation (very common, especially in men); inability to find pleasure in any activity (apathy); difficulty getting motivated in the morning; denial of depressive feelings
    • Thoughts: Indecisiveness: loss of self-esteem; persistent suicidal thoughts; negative comments, such as “I am a failure”, “It’s my fault” etc; concerns about financial situation; perceived negative change in status in the family
    • Feelings: Moodiness and irritability; sadness, hopelessness or emptiness; a feeling of being overwhelmed; worthlessness and guilt.
    • Physical symptoms: Altered sleep (increased or decreased); feeling tired all the time; unexplained ailments, especially aches such as backache or headache, digestive upsets, nausea, altered bowel habit, loss or change in appetite, significant weight loss or gain, palpitations, dizziness, agitation and wringing of hands or pacing the floor.

Elderly people most at risk of depression include those experiencing:

  • Significant chronic physical health problems, especially problems associated with chronic pain. At least 25 per cent of those suffering a heart attack, Parkinson’s disease, Alzheimer’s disease and cancer suffer from depression, with the rate for those having had a stroke being even higher. The first presentation of depression in the elderly often coindides with a physical illness / symptom.
  • Losses, including the loss of a partner or a friend, loss of independence, loss of mobility, loss of work or income. Loss of beloved pets can often cause problems.
  • Adverse side effects from medications. Medications that can exacerbate / cause depression include some blood pressure medications, steroids, analgesics (pain killers), antipsychotics and benzodiazipines. (Most sleeping tablets and medications for anxiety are types of benzodiaepines.)
  • Adverse effects from alcohol misuse. Alcohol can sometimes be used as a 'cure' for depressive symptoms / loneliness; usually with the opposite effect.
  • Social isolation / loneliness (About a third of older women live alone.) People living alone who may be at increased risk include:
    • those who have no children or who have a poor relationship with their children / other family
    • those who do not speak English well
    • those isolated due to lack of transport
  • The early symptoms of dementia
  • Change in living situation, especially if this involves loss of independence
  • Being in a high care facility. (Rates of depression in facilities such as nursing homes are about 50 per cent and in low care facilities are about 30 per cent.)
  • Admission to hospital
  • The anniversary of a particularly sad event, such as the death of a spouse

Some other important points regarding depression in the elderly include:

  • Unexplained changes in behaviour is a common presenting symptoms that is often missed and include:
    • social withdrawal
    • agoraphobia
    • self neglect, including loss of interest in their appearance and eating an inadequate diet.
  • Depression is often difficult to notice in people with dementia and a high level of suspicion needs to be employed by the carers of people with dementia, especially as depression is easier to treat when it is found early on. Try not to delay bringing it to a doctor’s attention.
  • The rate of suicide increases with age once people reach 50 years. (Chronic illness, pain, recent relocation and being without a partner increase suicide risk in the elderly.) Accidental overdoses of sleeping tablets etc and reviewing wills should be viewed with suspicion; as should the general suicide risk factors such a expressing severe hopelessness, thinking or talking about death or suicide, making suicide plans and giving away cherished possessions. Peopldemonstrating such behaviours need urgent psychiatric review.
  • Depression can often be a presenting symptom of a previously undiagnosed physical illness, including underactive thyroid, Alzheimer's disease, anaemia, infections, vitamin deficiency, cancer, cerebrovascular disease (stroke), and Parkinson's disease.
  • Preventable problems with hearing and sight are important factors that limitsocialisation and should be regularly checked. Issues include removing wax in the ears , the use of hearing aids and glasses and assessment and treatment of cataracts and glaucoma.

Using antidepressants in the elderly

In general, the selective serotonin reuptake inhibitors (SSRIs) are the best tolerated antidepressants in the elderly, with sertralie, escitalopram and citalopram being the most commonly used as they are associated with fewer drug interactions. (Other medications are appropriate in certainsituations.)

Many elderly patients who are prescribed antidepressant medication are already on other medications and all these medications can interact and cause side effects. To help minimise potential problems, it is best to start off with the smallest dose of antidepressant possible (often half the usual dose) and to increase doses slowly. Particular problems are dizziness and sedation as they can lead to falls and fractures.

Antidepressants can take longer to work in the edlerly and thus longer trials are needed (often six to eght weeks) before trying an alternate therapy.

As depression is often more chronic in older people, those with more severe episodes are often kept on therapy for two years.

 

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Further information on mental illness

Mental health resources

Mental Health Branch of the Department of Health and Aged Care  www.mentalhealth.gov.au
This site provides information about crisis supports and contacts, general mental health information, mental health information brochures / publications about specific topics such as depression, anxiety, information about suicide prevention etc.
Ph 1800 066 247

Beyond Blue: The National Depression Initiative www.beyondblue.org.au

Beyond Blue: Pregnancy and New Parents https://healthyfamilies.beyondblue.org.au/pregnancy-and-new-parents

ybblue (Beyond Blue’s youth program)  www.youthbeyondblue.com
Beyond Blue’s youth program

Black dog institute www.blackdoginstitute.org.au
Provides information for clinicians and patient education.

Black dog institute for young people aged 12 to 18 years www.biteback.org.au
Provides information for clinicians and patient education.

Sphere (For GPs) www.spheregp.com.au
Sphere is a national education health project aimed at increasing GPs rates of identification, effective treatment and management of common psychological problems.

Moodgym   www.moodgym.anu.edu.au
An interactive program of CBT, more aimed at depression, developed by the Centre for Mental Health Research at the Australian National University.)

Reachout www.reachout.com.au
A resource for young people with depression.

Self-Injury www.self-injury.net
A web site with information about youth self-injury; an increasing problem in western society. It is run by a young adult who has previously self injured and gives information about overcoming the problem.

Lifeline www.lifeline.org.au  Ph 13 1114
Lifeline provides an immediate counseling service for all people)

Kids Help Line www.kidshelp.com.au
A national 24 hour counseling service for children and young people)
Ph 1800 551 800

CRUfAD, The Clinical Research Unit for Anxiety and Depression www.crufad.com 
CRUfAD is a group of researchers and clinicians concerned with anxiety and depression. It is a joint facility of St Vincent's Hospital Ltd and the University of New South Wales in Sydney, Australia. The self-help section of the web site has useful information about both anxiety and depression for the general public.

Anxiety Panic Hub www.panicattacks.com.au
A consumer web site with a focus on meditation / mindfulness.

The Panic Anxiety Disorder Association www.panicanxietydisorder.org.au 
Provides good consumer information

Toughin it out  www.toughinitout.com  
A program detailing survival skills for dealing with suicidal thoughts.

Mindmatters   http://cms.curriculum.edu.au/mindmatters/index.htm
A program that introduces mental health education to secondary schools.

Inspire Foundation  www.inspire.org.au/   
For people aged 14 to 25

National e-Therapy Centre Swinburne University  www.anxietyonline.org.au  
Help with all types of anxiety disorders

 

Further reading on mental health topics

Rapee, R., Spence, S., Cobham, V. and Wignall, A. Helping your anxious child. A step by step guide for parents. New Harbinger, 2000.

Macquarie University Child and Adolescent Anxiety Unit
This unit runs 12 week courses for anxious children in the 6 to 12 year age group.
www.psy.mq.edu.au/muaru.

Rapee, R.M. (2001). Overcoming shyness and social phobia: A step by step guide. Sydney: Lifestyle Press.
Deals with social phobias and shyness

Wells, A. (1997) Cognitive therapy of anxiety disorders; a practice manual and conceptual guide. Chichester. John Wiley and Sons, 1997.
  
Beating the blues by Susan Tanner and Jillian Ball. Published by Susan Tanner and Jillian Ball. Distributed by Tower books.
A good book for issues dealing with the treatment of depression.

Don’t panic. Overcoming anxieties, phobias and tensions by Andrew Page. Published by Liberty One Media.
Deals with panic disorders, phobias and anxiety.

Aisbett, B. Living with it; a suvivor’s guide to panic attacks. Pymble, NSW. HarperCollinsPublishers, 1993.

Aisbett, B.Taming the black dog. Pymble, NSW. HarperCollinsPublishers, 2000.

Calrk, S. After suicide: help for the bereaved. Melbourne. Hill of Content Publishing Company Pty Ltd, 1995.

   

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