Norman Hoffman, M.D., F.R.C.P.C.
Director, McGill Mental Health Service
Across North America there has been a substantial increase in students seeking treatment for depression. The number of students diagnosed as being depressed has doubled over the past five years. The increased awareness of this mental health issue by professionals, students and the general public can lead to a better understanding of the nature of depressive symptomatology, and more responsive treatment modalities. There has, though, been considerable confusion as to what constitutes depression, and what treatments are most appropriate for a university population.
While ten years ago students presenting to a university mental health service would tend to state their problem as feeling down, sad or depressed, these days’ students are more likely to state that they think they have “a depression”. In the effort to educate the public and destigmatize depression, often with pharmaceutical industry funding, the notion of depression as a singular entity has been promoted. This is clearly erroneous, even according to the DSM, where depressions are classified as Major Depression, Dysthymia, Adjustment Disorder, Bipolar, or Cyclothymia. The issue is more confusing when dealing with actual patients. It is important to understand that the DSM does not describe actual disease entities. DSM diagnoses are primarily descriptive, and useful in establishing research criteria and a common “language” for clinicians. In dealing with real people they are helpful as guidelines, but do not replace clinical expertise. The validity of many of these diagnoses in adolescent/young adult populations has not been well established. Proper diagnoses and clinical understanding tends to take time, and cannot be done in one interview, and certainly not by relying on rating scales. Depressive symptoms in a young adult population tend fluctuate, and one cannot judge the severity of the problem based on the intensity of the depressive affect. Students who may seem severely depressed on first interview may show rapid improvement in mood, while those who show only mild depressive symptoms at first may later reveal very deep pathology. It is therefore crucial not to jump into a diagnosis, but to take a few sessions to build a therapeutic alliance and to investigate the problems.
There is also confusion as to what constitutes a “biological” depression, with clinicians often under the impression that “biological” depressions require medication. Research on Major Depression actually shows little difference in response between medication and other treatment modalities even in fairly severe depressions. It is important to recognize that research is usually limited to subjects with clear diagnoses with no significant other pathology. Actual patients rarely fit cleanly into one diagnostic category and often have underlying Axis II pathology, limiting the value of the research. The differentiation between biological and non-biological depressions is also misleading. All depressions are biological in that every emotion or thought is a result of the release of neurotransmitters in certain brain pathways. The notion of “diseased” pathways is often overstated, and certainly not suggested by DSM diagnoses. While diagnoses such as schizophrenia, bipolar disorder, or severe recurrent major depression may involve a disease process, the changes in neurotransmitter levels that may be found in many psychological conditions are likely due to combinations of chronic and acute biopsychosocial conditions. In other words, every experience in life can have an effect on how brain pathways are stimulated. Chronic stress can have long-term effects on brain functioning. Reduction of stress through psychological means can also effect brain functioning.
Depletion states occur when an individual suffers a psychologically significant loss to his self-esteem. Mood declines, often quite dramatically, energy, motivation and concentration deplete. Most people need regular refueling of their self-esteem to feel content within themselves. This refueling may be internally generated through one’s inner concept and experience of one’s abilities and achievements, both emotional and practical. However even the most secure individual will need some external validation of his self in order to maintain confidence. Individuals with more fragile self-esteem can be extremely dependent on outside validation in order to feel confident. Even minor insults to one’s self-confidence can be devastating to some people, especially if they have lost regular support networks. Repeated insults can lead to severe depressive states, though even in these, fluctuating moods are common. As energy, concentration and motivation decline, further failures are inevitable, leading to further narcissistic injuries. Thus, a downward spiral can easily occur in susceptible individuals. Therapy in these individuals is aimed at recognizing the injuries, both past and present, helping the person control self-sabotaging behavior, and reconnecting the person with more positive aspects of their self concept and with more reliable support systems. Medication may help in softening anxiety and dampening depressed mood.
Fragmentation states are related to a loss of psychic security. They can occur in almost any individual when there is a severe trauma. Individuals who have had very insecure or traumatic backgrounds can be very susceptible to these states, which may be provoked by relatively minor events. These states are characterized by high anxiety and severe dysphoric moods. The individual may feel suicidal, or may exhibit behavior aimed at alleviating the mood, such as binge eating or drinking, drug abuse, infliction of pain or self-mutilation. Dissociative states may be seen. Suicide is rare, though suicide attempts may be frequent. The attempt by the individual is to feel intact again, not to destroy himself or herself. Moods can fluctuate considerably, as can energy, concentration and motivation. The dysphoric states can last a few hours to a few days, though a person may be left feeling depleted or disconnected in between the acute states. In therapy it is crucial to provide a secure, consistent environment for the patient. Therapy is aimed at dealing with past and present disruptions to a basic sense of security. Acute life traumas are explored, but usually only when a sense of trust has been established and when fundamental security issues have been settled. Focusing primarily on acute traumas can be highly disrupting, and can prevent the individual from dealing effectively with their daily life.
Mourning states occur in response to a loss of a significant other or social milieu. These states can occur after a separation from home, a breakup, a death, or the loss of friends. Mood will tend to be low, possibly severely dysphoric, though the level of anxiety is usually lower than in the other state. However, it is possible that a person may experience a sense of fragmentation or depletion in response to a loss. Thus symptoms may be mixed. Motivation is usually compromised, as in face of the loss, little else feels important. A person may wish to isolate himself or herself or may feel anxious about being alone. Fears of illness, injury or death are common. Sleep disturbances, especially difficulty in falling asleep, frequently occur. When the loss is severe, these states may last for many months. In therapy, the person is helped to mourn the loss, deal with ambivalent feelings, and reconnect with the world. Medication may be useful to regulate sleep. Sometimes anti-anxiety medication may be helpful in acute situations.
These days many treatments have tended to focus on symptom reduction, using DSM criteria and research oriented scales to measure outcome. These treatments are limited both by the accuracy and the relevance of the diagnoses, the actual significance of the symptom reduction, and the lack of emphasis placed on emotional growth. Treatments that primarily promote control of symptoms may tend to discourage patients from assessing their life, their needs, and their emotional issues, but may be initially useful in giving an individual a sense of control over their life. Patients are also sensitive to overt or covert messages as to the expectations of the treating practitioners. Patients will often comply with expectations, hiding true symptoms from practitioners. When a patient is given only a few minutes to talk about their problems, they will tend to focus on acute symptoms, leaving out more complex problems. In clinical practice, frequently one gets a totally different picture of an individual’s life when one gives the patient the message that one have the time and interest in listening. There are no accurate shortcuts in assessing an individual’s emotional life.
Exploratory therapies are often most helpful in students. Bright young adults are often intrigued by their own emotional development and respond very well to any therapy that allows for emotional discovery. At times, techniques that help an individual contain their emotions may be helpful, but it is usually helpful to at some point lead the student to a deeper understanding of their emotional life. If a student does not respond to psychological intervention then two issues should be considered. Firstly, does the student have more severe longstanding personality issues that may take more time to address, and secondly, could medication be useful in helping with symptoms? Students that have shown patterns of repeated disturbed relationships and unstable moods will often not respond to short-term intervention. These students can do very well in therapy, but require extended time to develop a secure working relationship. Medication may be helpful in containing some of the dysphoric mood, but will generally not provide long-term relief without therapy. In general, with severely depressed students, medication might be considered if a student shows little response to a few sessions of therapy. Sleep disturbances should be addressed quickly, as frequently a few good nights sleep will alleviate depressed or anxious mood. Anti-depressant medication may be useful if a student feels overwhelmed by the intensity of their depression or anxiety. Research has shown that antidepressant medication has minimal beneficial effect in adolescents under the age of 18, with adverse effects often outweighing any benefit. Antidepressant medication has not been adequately studied in the young adult population, and we therefore rely on clinical experience. The modern anti-depressants appear to be largely mood dampeners. They will tend to dull intense affect in many people. This mood containing effect should not be taken to imply that a person has a “biological” illness, and an individual may be kept on the medication for only a few months after their affect calms down. Some students don’t like this mood dampening effect as they feel it distances themselves from their feelings. Individuals that show consistent depressed mood, with loss of all pleasure, and serious sleep, appetite and concentration difficulties should be considered for anti-depressant medication, but only after a thorough assessment. This determination can only be made after repeated interviews, though if a student has shown no response to a few sessions of counseling, a psychiatrist may be able to recommend medication after a proper one session interview. It is not appropriate in the university population to suggest to students that they have a “biological” problem unless they have been proven to have severe repeated episodes. While it is important to continue to destigmatize mental illness, this is best done by helping individuals deal with their emotional difficulties and needs rather than by labeling them.
Depression is a serious concern in our society and of particular concern among young adults. Depressed moods are highly treatable in the university population with psychological intervention remaining the treatment of choice for most individuals. It is crucial that universities provide quickly accessible treatment for students with mood disturbances. Proper treatment can make the difference between a student failing university and beginning a down ward spiral, or a doing well in life. It is our responsibility to ensure that young adults coming to university have the opportunity for both intellectual and emotional growth.
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