Wyoming Behavioral Institute

Women and DepressionNadine Dexter, WBI Director of Clinical Services

Statewide Videoconference

Nov. 13, 2006

What is depression?

Symptoms of depression include: Persistent sad, anxious or “empty” mood Loss of interest or pleasure in activities, including sex Restlessness, irritability or excessive crying Feelings of guilt, worthlessness, hopelessness,

pessimism Sleeping too much or too little; early-morning

awakening

What is depression?

Appetite and/or weight loss or overeating and weight gain

Decreased energy, fatigue, feeling “slowed down” Thoughts of death or suicide, suicide attempts Difficulty concentrating, remembering or making

decisions Persistent physical symptoms that do not respond

to treatment, such as headaches, digestive disorders and chronic pain

What is depression?

Major depression – “Unipolar” or clinical depression includes some or all of the symptoms for at least 2 weeks but frequently for several months or longer: Episodes can occur once, twice or several times

in a lifetime Affects twice as many women as men,

regardless of racial and ethnic background or economic status

The “Blues” vs. Depression

Depression The Blues

Essential distinction:

An illness A normal reaction to life situations

Duration: Persists Temporary

Symptoms: Multiple: Moods, Thoughts, Bodily Functions

Single: Moods

Suicide Potential: Can result in suicide Rarely produces suicidal thoughts

Treatment: Requires specific medical psychiatric treatment

Requires a good listener + time to heal

Grief vs. Depression

Grief Recognizable loss Open anger Crying Vivid dreams Episodic difficulty

with sleeping Responds to warmth Pleasure varies Others sympathetic

Depression If loss, seen as punishment Consistent sadness Anger not turned outward No crying or uncontrollable

crying Few dreams Severe insomnia, early morning

wakening Unresponsive unless pressured Restricts pleasure persistently Others irritated, not accepting

Major Depressive Disorder

Major depressive disorder is the leading cause of disability in the U.S. for people ages 15-44

Major depressive disorder affects 14.8 million American adults (6.7% of the U.S. population 18 and older)

Median age at onset is 32 Major depressive disorder is more prevalent in

women than in men

Types of Depressive Illness

Dysthymia – Same symptoms are milder and last at least 2 years People with dysthymia are frequently lacking in

zest and enthusiasm for life, living a joyless and fatigued existence that seems almost a natural outgrowth of their personalities

They can also experience major depressive episodes

Effects twice as many women as men, regardless of racial and ethnic background or economic status

Types of Depressive Illness

Manic-depression – “Bipolar disorder” is not nearly as common as other types of depressive illness and involves disruptive cycles of depressive symptoms that alternate with mania During manic episodes, people may become

overly active, talkative, euphoric, irritable, spend money irresponsibly and get involved in sexual misadventures

Men and women are equally vulnerable to bipolar disorder

Types of Depressive Illness

Seasonal affective disorder – May be an effect of seasonal light variation Most difficult months are January and February Women and younger persons are at greater risk Identifiable because there is full remission of

depression in summer months Symptoms occur at least two years

consecutively

Impact of Depression

Major depression is the leading cause of disability worldwide

For women in market economies, depression is the leading cause of years of healthy life lost

Causes of Depression

Genetic factors Risk higher for bipolar disorder Not everyone with a family history develops

the illness Depression can occur in people who have had

no family members with the illness

Causes of Depression

Biochemical factors Individuals with major depressive illness typically have

dysregulation of certain brain chemicals, called neurotransmitters

Sleep patterns, which are biochemically influenced, are typically different in people with depressive disorders

Depression can be induced or alleviated with certain medications

Some hormones have mood altering properties

Causes of Depression

Environmental and other stressors Significant loss Difficult relationship Financial problems Major change in life pattern Acute or chronic physical illness Substance abuse disorder (occurs in about 1/3

of people with any type of depressive disorder)

Causes of Depression

Other psychological and social factors Pessimistic thinking Low self esteem Sense of having little control over life events Tendency to worry excessively

Research findings

Adolescence Between the ages of 11 and 13 there is a

precipitous rise in the depression rates for girls By age 15, females are twice as likely to have

experienced a major depressive episode as males

Research findings

Adulthood For both men and women, rates of major

depression are highest among the separated and divorced and lowest among the married, although always higher for women

Rates of depression are highest among unhappily married women

Research findings

Reproductive events Menstrual cycle, pregnancy, post pregnancy, infertility,

menopause, and sometimes the decision not to have children are reproductive events sometimes resulting in depression

Hormones have an effect on the brain chemistry that controls emotions and mood

Women who experience major depression after childbirth very often have had prior depressive episodes even though they may not have been diagnosed and treated

Research findings

Reproductive events Pregnancy seldom contributes to depression and having

an abortion does not appear to lead to a higher incidence of depression

Women with infertility problems may be subject to a higher rate of depressive illness

Motherhood may be a time of heightened risk for depression because of the stress and demands it poses

Menopause is not associated with an increased risk of depression

Research findings

Victimization Women molested as children are more likely to have

clinical depression at some time in their lives Women who are raped as adolescents or adults have a

higher incidence of depression Women who experience physical abuse and sexual

harassment on the job may also experience higher rates of depression

Poverty Low economic status brings with it many stresses,

including isolation, uncertainty, frequent negative events, and poor access to helpful resources

Research findings

Later adulthood Studies do not support the belief that women are particularly

vulnerable to depression when their children leave home and they are confronted with “empty nest syndrome”

More elderly women than men suffer from depressive illness Widowhood is a risk factor for depression

About 1/3 of widows/widowers meet criteria for major depressive episodes in the first month after the death, and ½ remain clinically depressed 1 year later

Depression should not be dismissed as a normal consequence of the physical, social and economic problems of later life

Rurality and Mental Health

Stressful life events that are unique to rural environments have been linked to feelings of depression and worthlessness in many rural communities

High levels of stress may be the result of access to limited resources required to meet both personal and interpersonal needs

Non-metropolitan poverty rates continue to be higher than those in metropolitan regions across many demographic groups

Depression and Stress

The most commonly studied psychological disorder in rural areas is depression

Depressed persons report clinically and significantly worse mental and physical functioning than non-depressed persons

Additional factors associated with depression among rural women include: isolation, weather problems, and a lack of social, educational and child care resources

Community dissatisfaction is the strongest predictor of depression

Identifying Depression

Psychological complaints account for more than 40% of all patient visits to rural family practice practitioners

Rural family practice practitioners detect 50% less depression in their patients than do their urban counterparts

Even when mental health professionals are available near physician offices, only 5% of depressed patients receive mental health care

More than two thirds of the unidentified depression cases initially seen by family practitioners in rural primary care settings meet the criteria for major depression five months later

Identifying Depression

Rural women are unlikely to discuss the symptoms of depression with their primary care providers

Rural women frequently present in primary care settings with psychosomatic symptoms such as headaches, backaches, insomnia, fatigue, and abdominal pain

Suicide

More than 90 percent of people who kill themselves have a diagnosable mental disorder, most commonly a depressive disorder or a substance abuse disorder

Four times as many men as women die by suicide

Women attempt suicide two to three times as often as men

The cost of poor mental health

Mental and substance-use conditions are the leading combined cause of disability and death among American women and the second highest among men, yet millions go untreated

According to the Institute of Medicine, failure to deliver effective care to people with mental health and substance use problems results in significant costs to the nation's economy, including considerable costs to employers because of employee absenteeism, impaired work performance, days of disability, and on-the-job accidents

Total DALYs (millions)

Percent of Total

. All causes 98.7 .

1 Ischemic heart disease 8.9 9.0

2 Unipolar major depression

6.7 6.8

3 Cardiovascular disease 5.0 5.0

4 Alcohol use 4.7 4.7

5 Road traffic accidents 4.3 4.4

Leading sources of disease burden in established market economies, 1990

What is the impact of untreated mental illness?

The burden of mental illness on health and productivity in the United States is profoundly underestimated

Data developed by the World Health Organization, the World Bank, and Harvard University, ranks mental illness, including suicide, second in the burden of disease in established market economies

Mental illness emerged from the Global Burden of Disease study as a surprisingly significant contributor to the burden of disease

Breaking the Cycle

As individuals move into adulthood, developmental goals focus on productivity and intimacy including pursuit of education, work, leisure, creativity, and personal relationships

Good mental health enables individuals to cope with adversity while pursuing these goals

Untreated, mental disorders can lead to lost productivity, unsuccessful relationships, and significant distress and dysfunction

Mental illness in adults can have a significant and continuing effect on children in their care

Why people go without treatment

Cost or insurance issues were the most commonly reported reasons for not getting needed treatment among adults with serious mental illness who did not receive treatment (51.4 %)

Other commonly reported reasons were: not feeling a need for treatment (at the time) or

thinking the problem could be handled without treatment (32.7%)

not knowing where to go for services (28.1%),

Why people go without treatment

stigma associated with receiving treatment (26.9%)

did not have time (16%) treatment would not help (11.1 %) fear of being committed or having to take

medicine (10.5 %) reasons relating to access barriers other than

cost (4.1%)

Regional variations in treatment

Adults in the West had the lowest rate of treatment for mental health problems in 2003 (11.9%) compared with: 13.7% for those in the Northeast 14.3% for those in the Midwest 13.1% for those in the South

• The rate of outpatient treatment in the West decreased from 8.3 % in 2002 to 6.6 % in 2003

Wyomingites’ Mental Distress

Males

Females

ages 18-24

ages 25-34

ages 35-44

ages 45-54

ages 55-64

65+

Southeast

Southwest

Northwest

Northeast

Central

0.00% 2.00% 4.00% 6.00% 8.00% 10.00% 12.00% 14.00%

% reporting mental health was not good for 14 or more of last 30 days

Wyomingites’ Mental Distress

Wyomingites’ Mental Distress

Male

Female 18-2425-34

45-54

55-64 65+

SE

SWNW

NE Central

0

2

4

6

8

10

12

14

16

8+ days poor mental health in past 30 days

Who gets treatment?

In 2003, adults with family income of <$20,000 were more likely to have received treatment for mental health problems (15.4%) than those with incomes of: $20,000 to $49,999 (12.2%) $50,000 to $74,999 (13.3%) $75,000 or more (13%)

Who gets treatment?

Adults in families receiving government assistance were more likely to receive treatment for mental health problems in 2003 (19.3%) than adults in unassisted families (12.3%) Adults in assisted families were more likely than

those in unassisted families to receive inpatient treatment, outpatient treatment, or prescription medication

Is there a solution?

Research has contributed to our ability to recognize, diagnose, and treat these conditions effectively in terms of symptom control and behavior management

Medication and other therapies can be independent, combined, or sequenced depending on the individual’s diagnosis and personal preference

A new recovery perspective is supported by evidence on rehabilitation and treatment as well as by the personal experiences of consumers

The Good News

More than half of adults who received treatment for mental health problems in 2003 (57.5%) reported treatment improved their ability to manage daily activities "a great deal" or "a lot"

Treatment for Depression

Seek medical examination to rule out any physical illnesses that may cause depressive symptoms

Ask for physician or pharmacist review of medications – some medications can cause the same symptoms as depression

Seek psychological examination, and if recommended: Take medication Participate in psychotherapy

Treatment for Depression

Find support groups Exercise For SAD sufferers, phototherapy or bright

light therapy can help Antidepressant drugs may prove effective in

reducing symptoms

Preventing Depressive Episodes

Eat a balanced diet Get regular exercise (for SAD sufferers,

being outdoors on sunny days can be therapeutic)

Maintain a regular sleep pattern Avoid drugs and alcohol

Preventing Depressive Episodes

Take medication as prescribed Continue to take medications for at least 7

to 15 months after symptoms improve Continue with cognitive-behavioral therapy

even after medications have been stopped Continuing counseling for 2 years after

medications stop lower rates of relapse

Wyoming Behavioral Institute

Free, confidential 24 hour toll free assessment hotline:

1-800-457-9312