Depression After Stressful Event

by Dr. Milton Lum

Life has its ups and downs. When down, one feels unhappy or miserable. This can last for a few days. However, depression, which is also known as depressive illness, is different. The unhappy feelings can last for weeks or months and start to interfere with the activities of daily living.

It is estimated that about one in 10 persons will suffer from depression at some point in life. However, the true incidence may be different because many depressed people do not seek medical help or the diagnosis is not made.

In general, women are more likely to suffer from depression than men, with more than twice the number of women with the condition compared to every man. However, as men are less likely to seek help, this may contribute to their greater tendency to commit suicide.

Depression affects all ages, including children. The likelihood of depression is increased if there is a family history of the condition.

Depression can be a severe illness. However, with appropriate diagnosis, treatment and support, most sufferers can make a full recovery.


There are various causes for depression, and several factors that can precipitate it. They include stressful life events, e.g. illness, worries about job or money, separation, divorce, bereavement. When stressful events occur, the majority of people need time to get over it. But the risk of depression increases if one ceases socialisation with family and friends.

Some pregnant women are prone to depression after childbirth ('postnatal blues'). This has been attributed to hormonal and physical changes, as well as the additional responsibilities after giving birth.

The risk of depression is increased if a diagnosis of a chronic or life threatening illness, eg heart attack, cancer, is made. Head injuries are often an unrecognised cause of depression. Even minor head injury can result in damage to the pituitary gland, which affects the hormones controlling the thyroid gland, causing symptoms like tiredness and decreased libido, which can lead to depression.

Some individuals are prone to depression because of personality traits, like low self esteem. This may be due to genetic inheritance or life's experiences, which can have a marked effect on one's perception of oneself later in life. A family history of depression increases the risk.

The risk of depression is also increased if one is isolated from family and friends.

It is not uncommon for a number of causes to act in combination, eg illness followed by separation or divorce.

Substance abuse or excessive alcohol consumption increases the risk of depression. The alcohol or drugs or isolation leads to poor self esteem, which in turn leads to a vicious cycle of further isolation and increased consumption of drugs or alcohol.

Increasing age and difficult socio-economic circumstances are additional factors that increase the risk of depression.

Clinical Features

The clinical features of depression are varied. Although the clinical features of grief are similar to that of depression, there is a difference between them. The former is a response to a loss, whilst the latter is an illness. Depression affects the sufferer's work, family and social life, unlike that of a person who is in grief.

The features of depression are also present in other conditions, like bipolar disorders, in which the sufferer alternates between depression and mania. The symptoms are similar to that of depression, but during the manic phase, the sufferer's behaviour can cause self-harm.

The symptoms of depression may be psychological, physical and/or social.

The psychological symptoms include continuous feelings of hopelessness and helplessness, low self-esteem, feelings of guilt, irritability, poor motivation, little interest in surroundings and events, difficulty in decision making, suicidal thoughts, and reduced libido.

The physical symptoms include changes in appetite or weight, menstrual cycle changes, constipation, reduced libido, altered sleep patterns, vague aches and pains, slow movement or speech and tiredness.

The social symptoms include poor work performance, avoidance of family and friends, lack of interest in enjoyable activities, and difficulties with family members.

The features of depression may be insidious without the condition being recognised. Its seriousness is described by doctors as follows :

* Mild depression has some impact on daily life.

* Moderate depression has significant impact on daily life.

* Severe depression makes the activities of daily life nearly impossible.

When a person with features of depression consults a doctor, the latter will conduct a physical examination to exclude conditions which present with similar features, eg hypothyroidism.

A diagnosis of depression is made through interviews and questionnaires. There is no laboratory test for depression. It is crucial that one is honest and frank with the doctor, who can then make a diagnosis after excluding other physical or mental health conditions.


Management is determined by the type of depression and the patient’s individual circumstances. It usually involves a combination of self-help, talking therapies, counseling, and medicines.

Mild depression often improves by itself. Talking to a family member, doctor, relative, or friend can be helpful. Antidepressant medicines are not usually prescribed as first-line treatment.

Moderate depression or mild depression that is not improving is managed with talk therapy or antidepressant medicines.

Severe depression is managed with talk therapy, behaviour therapy, and antidepressants. A combination of treatment modalities is usually more effective. The assistance of a mental healthcare team, which includes a psychiatrist, psychologist, and nurses, is helpful.

Cognitive behaviour therapy helps a patient understand how current behaviour and thinking is having an effect on him or her. It focuses on helping and teaching the patient how to alter his or her thinking and behaviour, to enable the patient to challenge negative thoughts and feelings.

Counseling helps a patient discover alternative solutions to his or her problems. The counselor assists the patient, but does not tell the patient what to do.


There are several types of antidepressants. They are categorised into a selective serotonin reuptake inhibitors (SSRIs), tricyclic antidepressants (TCAs), serotonin norepinephrine reuptake inhibitors (SNRIs) and monoamine oxidase inhibitors (MAOIs).

Antidepressant medicines are not addictive, but withdrawal symptoms are common if they are stopped suddenly or a dose is missed. The side effects vary with individuals and the type of antidepressant.

SSRIs increase the brain’s levels of serotonin, a compound which is thought to improve a person’s mood. They are as effective as the older TCAs, and have fewer side effects. The side effects of SSRIs, which include dry mouth, nausea and headaches, ease off with the passage of time.

Except for fluoxetine, SSRIs are not prescribed to children because there are reports of increased risk of self-harm and suicidal tendencies.

TCAs increase the brain’s levels of serotonin and noradrenaline, thereby improving a person’s mood. The side effects, which include dry mouth, blurred vision, constipation, problems passing urine and drowsiness, usually ease off after about 10 days.

SNRIs, which came on the market more recently, increase the brain’s levels of serotonin and noradrenaline, thereby improving a person’s mood. Their mode of action differs slightly from the SSRIs and TCAs.

MAOIs are sometimes used to treat depression. The side effects of MAOIs include blurred vision, nausea, trembling, increased appetite, and difficulty sleeping. They can also cause a marked increase in blood pressure, leading to severe headache, chest pain, rapid heart rate and stiff neck, which is a medical emergency.

People who are taking MAOIs must not take food containing tyramine, eg pickled fish or meat, cheese. One should also not consume alcohol or fermented liquids. A list of such foods will be provided by the doctor.

As there are interactions between the MAOIs and many medicines, one should only consume the latter after checking with the doctor.

If there is no improvement after several different types of antidepressant medicines, the patient may be prescribed lithium in addition to the current medicine. The effectiveness of lithium carbonate or citrate depends on its optimum blood level. Excessive levels can be toxic. Because of these reasons, regular blood estimations of lithium are necessary.

Electroconvulsive therapy (ECT) is prescribed for severe depression when antidepressant medicines and other treatment modalities have not been effective. ECT involves giving an electrical 'shock' to the brain via electrodes placed on the head. It is usually done under anaesthesia. The side effects include muscle aches, nausea, headache and memory problems.

Regular follow-up is necessary for the management of depression. It is essential to follow the advice of the doctor, particularly on the consumption of antidepressant medicines.

With the help of family, the attending doctor and other healthcare professionals, relatives and friends, the majority of sufferers from depression can and do recover.

More info on DEPRESSION here.

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