Laval Families Magazine continues with its new series on mental health. In this issue, we conclude our discussion on depression with the third and final installment on the vast topic of clinical depression. Dr. Mary Tsonis, psychologist and founder of Your Psychology Clinic in Laval, answers Lori Leonard’s questions.

Q: Are most patients seen on an out-patient clinic basis or do people have to be hospitalized?
A: It depends on the severity of the depression and any other concomitant factors or problems that accompany depression.

Q: When or how does depression turn to suicide?
A: Not everyone who suffers from clinical depression is at increased risk for suicide or considers suicide; however there is evidence to suggest that people with depression and bipolar disorder are at a considerably higher risk, especially when they are in a depressive episode. The risk of suicide increases if the person is actively using drugs and/or alcohol, or has a history of self-harm, has made a previous suicide attempt or if there is a family history of suicide or suicide attempts, is unwilling to get help because of stigma, is socially isolated, has intense feelings of anger, has a history of impulsive or aggressive behaviour, or feels cut off from others because of sexual identity, culture or race.

Some of the most overwhelming symptoms of depression are thoughts of worthlessness, hopelessness, and suicide. When the pain of depression is so great, some people may consider suicide as a rational and reasonable way to end what they feel as an unbearable and unending psychological pain. They do not want to die but they see suicide as the only way of ending their pain, as the only relief. Thoughts of taking one’s own life are very common in mood disorders that they are considered a symptom of the disorder. Thinking becomes clouded, or constricted, in depression, and they see suicide as the only way out, as the only solution to their problems. The way they see the world, their problem-solving capacities are affected. They may be consumed with feelings of guilt and failure. They lose all hope. Because of their illness, they begin to think that others would be better off without them. For a few, psychosis may lead to internal voices that instruct them to take their own lives, or to self-destruct.

People with depression carry out 80% of suicides. About 15 to 20% of people with significant or chronic depression commit suicide. Women make three to four times more suicide attempts than men, but men complete suicide more often, probably because they choose methods that are more lethal. Males tend to attempt suicide early in a depressive episode, compared to women in the later part of the episode. Fifty to 80% of older patients who commit suicide have been shown to have major depression. Suicide accounts for about 25% of all deaths among 15 to 24-year olds, and about 16% of all deaths among 24-44 year-olds.

Q: What are the sign to watch out for?
A: Signs to watch for in loved ones who are depressed include: voicing thoughts of suicide, having a specific plan, voicing thoughts of being a “burden” to others, or preparing for death (e.g. by giving away cherished personal possessions, making a will, putting personal affairs in order, telling others their final wishes). There may even be a lift in the person’s mood after the decision to end their life has been made. Thoughts of suicide or other “signs” must be taken seriously. If a loved one is openly expressing a wish to die, take them to an emergency room or call 911.

Q: Are there support groups or people who meet to discuss depression?
A: Yes, there are live and online support groups.

Q: Is there a stigma associated with depression, such as in the workforce?
A: Unfortunately, there is still definitely a stigma attached to being depressed. People are afraid about their family finding out, or about what their employer would do if they found out. People with depression unfortunately also report feeling blamed or judged by their doctors and even by mental health professionals. Stigma is dangerous as fear of judgement can prevent people from getting the help that they need. However, people with depression may actually SHARE these harmful beliefs or attitudes about depression and therefore blame themselves for their illness. Self-stigma is especially dangerous since it can lead to people to thinking that they are weak, they are not as good or worthy as others, and feeling as if in some way they are deserving of some kind of punishment. In the workforce, there are employers who will see employees with depression as poor performers rather than as persons struggling with an illness.

Many employers now offer Employee Assistance Programs (EAPs) where confidential counsellors are available to help employees with mental health issues such as depression. The Canadian Disability insurance industry have published figures that show that 75% of short term disability claims, and 79% of long-term disability claims are for mental illness, primarily depression! The fastest growing category of disability costs for Canadian employers is for depression. Nonetheless, despite these numbers attesting to how common depression is, there is a lot of shame in disclosing that one is depressed, even to one’s self.

Q: Once someone has experienced depression, can it return in life later on?
A: Yes it can. Once you have an episode, you are at greater risk for having another one, but it is also possible to have one single episode of major depression without any recurrence in one’s lifetime.

Q: How does nutrition and lifestyle affect depression?
A: While our understanding of drug and psychotherapy treatments for depression have come a long way, research is increasingly providing support for the impact of lifestyle on the management of depression. That is, on the impact that healthy eating, sleeping and exercise have on our moods and mental health, and not just on our physical well-being. Research is amply showing that our diets, our sleeping and exercise habits affect our brain chemistry. Symptoms such as anxiety, fear, ruminations (or thoughts that occur over and over) interfere with sleep. The lack of sleep leads to fatigue, inactivity and a depressed mood. After a bad night’s sleep, a depressed person may take a long afternoon nap out of exhaustion. Then they will have difficulty falling asleep at night. They get into a pattern of sleeping late, not being able to get out of bed, and/or sleeping during the day. This interferes with activities of daily living, and leads to greater feelings of guilt, failure and self-deprecating thoughts (e.g. I haven’t done anything all day) and negative thoughts precisely because of lack of sleep and which support the depressive mindset (e.g. I am not getting better, I will never be better, etc.).

Similarly, research is supporting the importance of exercise as an important component to recovery from depression, likely as a result of the impact on our brain chemistry. Finally, when we are depressed and have no appetite we cannot rely on feelings of hunger; we have to eat regular, healthy meals throughout the day, even if not hungry! Or if tempted to indulge in, or over-eat rich comfort foods, high in fat or sugar, it is important to remember that these foods will affect blood sugar, energy levels, neurotransmitters levels, etc.