Introduction

Depression is an extremely common condition yet the stigma that still surrounds mental health difficulties makes it somewhat mysterious and hard to talk about, for some.

Add to that the fact that it is a complex and highly varied disorder, it’s no wonder there is confusion and misunderstanding about it.

As depression is more common in nursing now than ever, in this article I’m going to outline some of the basics about what depression is and what to do if you think you are struggling with it.

As the topic of effective treatments for depression is a highly broad one, I’ll cover these separately in other articles, though some other useful resources are presented at the bottom of this article.

What is depression?

Depression is a psychological disorder in which the person experiences a range of psychological, physical and cognitive symptoms. 

Around the world, doctors, psychiatrists, psychologists and other mental health professionals have developed different tools to diagnose mental disorders. 

Two of the most common are the Diagnostic and Statistical Manual of Mental Disorders (DSM) and the International Classification of Diseases (ICD). 

The DSM-5 outlines several criteria to make a diagnosis of depression:

The individual must be experiencing five or more of the below symptoms during a 2-week period and at least one of the symptoms should be either (1) depressed mood or (2) loss of interest or pleasure.

• Depressed mood most of the day, nearly every day.
• Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day.
• Significant weight loss when not dieting or weight gain, or decrease or increase in appetite nearly every day.
• A slowing down of thought and a reduction of physical movement (observable by others, not merely subjective feelings of restlessness or being slowed down).
• Fatigue or loss of energy nearly every day.
• Feelings of worthlessness or excessive or inappropriate guilt nearly every day.
• Diminished ability to think or concentrate, or indecisiveness, nearly every day.
• Recurrent thoughts of death, recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.

Additionally, the symptoms must be causing the person distress and/or be interfering with their usual day-to-day activities such as leisure, relationships, work etc. 

This clarification is important as it helps professionals distinguish between what might be a relative low-patch in someone’s life, as compared to the more serious and debilitating reality of depression.

What causes depression?

“Are you depressed because your boyfriend broke up with you?”

This may be the kind of innocent question you receive from a concerned friend, and indeed, we all try to search for simple answers to make sense of our lives.

Whilst in some cases, someone might be able to point to a very specific event that led to the development of a depressed mood, in many other situations, it’s not that clear cut.

Unfortunately, depression is a beast that does not lend itself to simple diagnosis or explanation. 

There are always multiple different reasons, or what psychologists call “risk factors”, for developing depression. 

This is why one person’s breakup may lead to the development of severe depression, whereas another person may find themselves relatively unscathed by such a situation.

In general, we know that there are several key factors that increase or decrease someone’s risk for developing depression:

Biology – genetics (family history makes it more likely to develop it), poor diet with high sugar/high processed foods, not enough (i.e. < 7 hrs per night) or too much sleep, inconsistent sleep, lack of regular physical activity and exercise, smoking, other ongoing physical illnesses (e.g. hypothyroidism, cancer, chronic pain).

Social factors – upbringing and exposure to maltreatment as a child, lack of social support, lower-income, living in densely populated areas, being single and not married, having a child with a disability or chronic condition, exposure to stressful events, nature of your job (e.g. harassment and abuse), substance use including excess alcohol.

Psychological factors – personality characteristics, coping styles, resilience, stress vulnerability, psychological flexibility, optimism, self-compassion.

Gender  – depression is approximately 1.7 times more likely in women than men, a robust finding in the literature which is thought to be due to biological differences rather than socioeconomic factors.

A combination of all these factors helps explain why any given person may become depressed. 

It is also important to note that depression does not always follow a linear path, for example being easily traced back to the aftermath of a single event.

Are there different types of depression?

As with any condition, physical or mental, there is a range of intensities with which depression can present. 

Most people who suffer from depression will experience it in its mild form (which is still a serious issue), but others will experience additional symptoms and be more affected in their lives.

At worst, the most severe depression can lead to a complete retraction and withdrawal from life to the extent that the person fails to meet their own basic needs. Moreover, self-harm and suicide can occur when depression becomes more severe too.

Up to half of the people who experience depression will suffer from at least one further episode and for some, it may reoccur multiple times. 

Recent research suggests that some of the main risk factors for reoccurrence include incomplete treatment and resolution of the initial depressive episode, a history of childhood maltreatment, and a history of previous depressive episodes (Buckman et al, 2018).

This means that with every new episode of depression you experience, your risk of getting it again increases. This really highlights the importance of seeking treatment early the first time around.

There is also some new research that suggests highly variable routines, in particular irregular and long sleep cycles create a risk for relapsing depression (Kumagai et al., 2019).

Researchers have also tried to put different types of depression into neat categories to help understand the different ways it presents. Some of these are listed below:

• Major depressive disorder (mild, moderate and severe) or “unipolar” depression, meaning the main problem is with depressed mood.
• Recurrent or relapsing depression, in which the person has had more than one episode. 
• Depression with psychotic features, where the person’s depression is so severe they have disturbances in thought and perception, involving either hallucinations and or delusions.
• Bipolar depression, in which the person experiences shifting states of depressed mood, followed by episodes of highly abnormal elevated mood.

Whilst these categories and diagnoses are to some extent helpful in designing beneficial treatments for depression, they also, in my opinion, oversimplify what is a complex disorder.

Diagnostic categories can also lead to problems with stigma and also some people simply don’t like being put in a tick box category.

I’ve worked with a number of people who don’t like to use the word “depression” and I certainly haven’t told them, “well you need to accept that this is your diagnosis”. We simply work on language they are comfortable with and proceed with treatment.

The important message is that if you feel you are depressed, a good doctor or mental health professional will try to understand your unique history and circumstances in detail and not just look to put you in a box for the purposes of treatment. 

You are an individual and should be treated as such.

How do I know if I’m depressed?

If you are a nurse reading this, then chances are you either suspect you are depressed or know someone you are concerned about. 

If you read through the above symptom list and felt like you were saying “yep, that’s me” a lot, and you identified several of the risk factors as being relevant for you, it is highly likely you are suffering from depression.

There are a number of self-report questionnaires which can also give an indication of whether you meet the criteria for depression. 

One of the most commonly used is the Patient Health Questionnaire-9. You can download it HERE.

Add up the scores and if your total is 10 or more, this is a good indication you are experiencing major depressive disorder.

If this is the case, see below for further information about what to do.

Acknowledging depression can be hard

I know from personal experience how it can be hard to acknowledge having a problem with mental health.

When I was 21, I suffered a severe depressive episode. 

I spent months spiralling further and further into oblivion.

I let the depression get so severe that I was suicidal, self-harming and had an active plan to end my life.

I didn’t feel like I could talk to anyone about how I was really feeling most of the time as I was embarrassed and ashamed. 

“You should be able to fix this yourself”, I would continually tell myself.

This fed further into the worthlessness I felt about myself.

If I had lived in a place where access to lethal means was easier, I have no doubt I would be dead now. 

Luckily, I made the choice to begin telling a few close people a little bit about what was going on for me. 

As I received compassion and not ridicule from these friends and family, I realised I needed to open up.

Eventually, I built up the courage to see my GP. I will never forget this consultation. 

As I sat in his office, I began to cry vigorously as I revealed what felt like a huge secret I’d been keeping.

“I think I’m depressed”, I squeaked through a fountain of tears.

“It’s okay, I’m here to help”, said the doctor.

In that instant, it was like the blanket of shame had started to retract. 

Simply in the act of acknowledging the depression and sharing it with someone else who cared, I was able to take the first and most crucial step in what was in my case, a journey that saved my life.

After that, it wasn’t easy, but after several treatments (anti-depressants, therapy) and adjustment of my lifestyle, I recovered, and have never suffered depression again.

I share this with you because I know from personal experience that many people are out there who are suffering in silence.

My hope is that you will reach out to someone you know cares about you and take that first step in receiving the proper help that is available out there.

I have provided some signposting below on where you can go if you are feeling depressed, but if you ever want to reach out to us at Nurse Wellbeing Project then we’re a compassionate bunch who will listen. 

Support for depression

If you are feeling suicidal and feel imminently unsafe, contact 999 immediately. You can also call one of the numbers below to receive support from trained professionals:

National Suicide Prevention Line (UK) – 0800 689 5652

Support Line: 01708 765200

The NHS Practitioner Health Service is a designated service for NHS staff. You can find their website here – https://www.practitionerhealth.nhs.uk/support-services-access-to-therapy.

GPs and Improving Access to Psychological Therapies

If you think you are depressed, I recommend you go to your local GP who will refer you to your local psychology service. They will be able to quickly allocate you to a worker who can assist with advice and treatment options.

You can also check out the following website, which provides lots of links to mental health resources for healthcare workers:

Healthcare Worker’s Foundation – https://healthcareworkersfoundation.org/nhs-workers/counselling