Welcome back to the Mental Health First Aid Introduction.
Feeling blue
Today, you’ll learn….
- The signs, symptoms, risk factors and effective interventions for depression & suicide.
- The importance of early intervention for depression & suicide.
What is depression?
The word depression is used in many different ways. People may feel sad or blue when bad things happen. However, everyday ‘blues’ or sadness is not a depressive disorder. People with the ‘blues’ may have a short-term depressed mood, but they can manage to cope and soon recover without treatment.
The depression we are talking about in this module is major depressive disorder, a type of mood disorder. Major depressive disorder lasts for at least two weeks and affects a person’s ability to carry out their work and usual daily activities, and to have satisfying personal relationships.
Depression is when someone has a low or irritable mood, loses interest or enjoyment in activities they normally like, or has a lack of energy or is overcome with tiredness. Depression is a mood disorder because it affects the way people feel (their mood). To be diagnosed with clinical depression or major depression, a person must have had some symptoms for at least two weeks, and their ability to carry out their work or usual daily activities, or their ability to have satisfying personal relationships, is being affected by their low mood. See also Mood disorder.
According to the WHO World Mental Health Surveys, the percentage of adults with a depressive or other mood disorder per year varied between 3.1% and 9.6%.
The results are difficult to compare across countries as there may be cultural differences, including how willing people are to report symptoms of mood disorders in a survey and subtle differences between languages in the meaning of words describing symptoms of mood disorders. Also, the European countries only measured depressive disorders, while Japan and USA also included bipolar disorder.
Mood disorders:
- are around twice as common in women as in men, except for bipolar disorder, which is equally common in women and men.
- often have their first onset during adolescence or early adulthood.
- often co-occur with anxiety disorders and substance use disorders
- are often recurrent.
Signs and symptoms of depression
If a person is clinically depressed, they will have five or more of the symptoms in this list (including at least one of the first two) nearly every day for at least two weeks.
Not every person who is depressed has all these symptoms. People differ in the number of symptoms they have and also how severe the symptoms are. Even if a person does not have enough symptoms to be diagnosed with a depressive disorder, the impact on their life can still be significant.
Signs and symptoms of major depressive disorder
- An unusually sad mood
- Loss of enjoyment and interest in activities that used to be enjoyable
- Lack of energy and tiredness
- Feeling worthless or feeling guilty when they are not really at fault
- Thinking about death a lot or wishing to be dead
- Difficulty concentrating or making decisions
- Moving more slowly or sometimes becoming agitated and unable to settle
- Having sleeping difficulties or sometimes sleeping too much
- Loss of interest in food or sometimes eating too much. Changes in eating habits may lead to either loss of weight or putting on weight.
What depression may look and feel like
A person who is depressed may be slow in moving and thinking, although agitation can occur, have slow and monotonous speech, show a lack of interest and attention to personal hygiene and grooming, look sad and depressed, be anxious, irritable, and easily moved to tears. However, in mild depression the person may be able to hide their depression from others, while with severe depression the person may be emotionally unresponsive and describe themselves as ‘beyond tears’.
Onboard, crew might notice some of the following:
- Decreased productivity
- Working long hours to get usual workloads completed
- Morale problems
- Lack of co-operation
- Safety problems, accidents
- More absences from work
- Difficulty completing work on time
- Frequent complaints of being tired
- Complaints of unexplained aches & pains
- Alcohol or other drug misuse.
Sometimes when a person does not recognise depression in their friend or colleague, they may judge them as lazy, self-centred, ‘not pulling their weight’, ‘not a team player’, having a poor work ethic or being incompetent.
Unfortunately, these attitudes only serve to reinforce the depressed person’s feelings and beliefs of their inadequacies and worthlessness.
EXAMPLE
Caroline and her friend are in the crew mess. Caroline’s crew do not know she is depressed.
Because they do not know any better, they say…
“Caroline looks tired and burdened. I know she has problems but don’t we all?”
“She needs to stop feeling sorry for herself.”
Meanwhile…
Caroline thinks it’s all hopeless …
“I’m useless. I will never get past my problems – there’s just no way for me to dig myself out of this hole. Why bother trying? I’m useless at everything – a total failure.”
Carolina’s crew would benefit from education & Mental Health First Aid. As my favourite nursing mentor once said.
“Put yourself in someone else’s moccasins….
Risk factors for depression
Depression has no single cause and often involves the interaction of many diverse biological, psychological and social factors.
Refer to the factors that increase a person’s risk of developing depression in Essential Information in the Resources tab, or look at the list of risk factors of your MHFA International Manual, then try the activity.
Some medical conditions and medications can cause or exacerbate depression.
Some medical conditions:
- Endocrine disorders (hypothyroidism – thyroid gland is underactive, reduced oestrogen, or Cushing’s disease)
- Brain injuries and diseases (stroke, head injury, epilepsy, hypertension, diabetes, or Parkinson’s disease)
- Acute and chronic infections (mononucleosis, hepatitis, HIV and AIDS)
- Deficiency states (pernicious anaemia)
Autoimmune disorders (systemic lupus erythematosis)
- Some forms of cancer
- Recent heart attack
- People with migraine are three times more likely to develop depression and people with depression are three times more likely to develop migraine than control subjects.
Some medications and drugs:
- Some anti-hypertensives including beta blockers
- Corticosteroids (to treat various inflammations)
- Benzodiazepines (as a relaxant – long-term use is the problem)
- Parkinson’s medications (adjust levels of dopamine)
- Hormone altering meds (e.g. oral contraceptives)
- Stimulants (for fatigue, ADHD, e.g. amphetamines)
- Anticonvulsants (to treat seizures)
- Proton pump inhibitors and H2 blockers (to suppress secretion of gastric acid)
- Statins and other lipid lowering drugs
- Anticholinergic drugs (to slow the activity of the intestine)
- Chemotherapies (e.g. interferon)
- Isotretinoin (to treat severe acne)
- Opioids (painkillers, e.g. codeine, pethidine, morphine)
- Alcohol, cannabis, cocaine and ecstasy.
- Effective interventions
A variety of health professionals can provide treatment to a person with depression. They are:
- General practitioners (family doctors, primary care physicians)
- Psychologists
- Counsellors
- Psychiatrists
- Mental health nurses
- Allied health professionals such as occupational • therapists and social workers.
In most countries, a depressed person would be admitted to hospital only where the depression is severe or there is danger a person might harm themselves. Most people with depression can be effectively treated in the community.
In my experience as a Life Coach & Mental Health/Trauma Nurse, I’ve found that people generally recover from depression and lead satisfying and productive lives. I work with my clients/crew to rule out physical causes, I often refer clients to a GP when necessary to prescribe medication if needed, and refer on to a mental health professional. I refer, because I believe in a multidisciplinary approach to health care.
I also recommend counselling (Sarah at British Counselling is amazing)and some complementary therapies and lifestyle changes which have some scientific evidence for effectiveness with depression, such as exercise and self-help books or online therapy based on cognitive behaviour therapy (CBT).
I asked a colleague, Tina a practicibg psychologist and ex yachties from Australia, her thoughts….
“In my experience as a psychologist”
Says….
“I predominantly use cognitive behaviour therapy (CBT), but occasionally draw on other evidence-based therapies”
There is good evidence for the following psychological therapies in the treatment of depression:
- Cognitive behaviour therapy (CBT)
- Mindfulness based cognitive therapy
- Interpersonal psychotherapy
Behaviour therapy (also called behavioural activation)
- Marital therapy (also known as couple therapy)
- Problem solving therapy
- Psychodynamic psychotherapy
- Reminiscence therapy for people over 65 years
- Self-help books based on CBT
There is a range of treatments available for both depression and bipolar disorder. Which is where psychiatrists become important.
The following medical treatments are known to be effective:
- Antidepressant medications
- Antipsychotic medications
- Mood stabilisers
- Electroconvulsive therapy (ECT)
- Transcranial magnetic stimulation (TMS).
Early intervention
Early intervention is very important. The duration of untreated depression influences the long-term course of the depression and severity of episodes.
Once a person has had an episode of depression they become more prone to subsequent episodes. They may fall into depression more easily with each subsequent episode. For this reason, some people go on to have repeated episodes throughout their life.
To prevent this pattern occurring, it is important to intervene early with a first episode of depression to make sure it is treated quickly and effectively.
EXAMPLE
You’ve been concerned about Carla, a crew member who hasn’t seemed herself for quite some time. She hasn’t been involved with things on board that she usually enjoys. You think she may be depressed. You decide to discuss it with her.
As a mental health first aid crew officer, if you believe someone is experiencing symptoms of a mental health problem, you would use the Mental Health First Aid Action Plan, discussed in the first issue 1/4 as a guide about how to approach the person and see if there is anything you can do to assist them.
EXAMPLES ON WHAT TO DO
When approaching someone you believe may be depressed choose a suitable time and a space where you will both be comfortable.
What if the person doesn’t want to talk?
When approaching someone who you believe may be depressed, let them know that you’re available to talk when they are ready; do not put pressure on them to talk right away. It can be helpful to let the person choose the moment to open up.
However, if the person does not initiate a conversation with you about how they are feeling, you should say something to them.
You might mention to Carla that some of the symptoms you have observed suggest that she may be experiencing depression. You could explain to her that mental health problems can make it difficult to manage work, relationships and day-to-day tasks, and that effective treatment is available.
Remember that you must respect the person’s privacy and confidentiality unless you are concerned that they are at risk of harming themselves or others.
Crises associated with depression
As you approach and engage with Carla, you also need to assess if she is in crisis and, if so, to assist with this crisis.
What could the crises be?
Two main crises that may be associated with depression are:
- The person has suicidal thoughts and behaviours
- The person is engaging in non-suicidal self-injury
We will focus on helping someone who is having thoughts of suicide, next.
Myths and facts about suicide
Suicide is a significant risk for people with depression. A person may feel so overwhelmed and helpless that the future appears hopeless. The person may think suicide is the only way out. Sometimes a person becomes suicidal very quickly, perhaps in response to a trigger (such as a relationship breakup or arrest), and act on their thoughts quickly and impulsively.
However, not every person who is depressed is at risk for suicide and nor is everyone who is at risk of suicide necessarily depressed. The risk is increased if they have also been using alcohol or other drugs.
Facts on suicide
In 2012, the suicide death rate in developed countries was 13 per 100,000 persons. While suicidal behaviours are more common in females in these countries, completed suicide is 3.5 times more common in males (20 per 100,000 for males and 6 per 100,000 for females).
According to the WHO World Mental Health Surveys, in developed countries 2% of adults think about suicide, 0.6% make a plan for suicide and 0.3% attempt suicide over a 12-month period.
The main reasons people give for attempting suicide are:
Needing to escape or relieve unmanageable emotions and thoughts. The person wants relief from unbearable emotional pain, feels their situation is hopeless, feels worthless and believes that other people would be better off without them.
Desire to communicate with or influence another individual. The person wants to communicate how they feel to other people, change how other people treat them or get help.
People are at greater risk of suicide if they have:
- A mental illness
- Poor physical health and disabilities
- Attempted suicide or harmed themselves in the past
- Had bad things happen recently, particularly with relationships or their health
- Been physically or sexually abused as a child
- Been recently exposed to suicide by someone else.
Suicide is also more common in certain groups, including indigenous people, the unemployed, prisoners, and gay, lesbian and bisexual people.
Asking about suicidal thoughts
If you have seen some warning signs that Carla is feeling suicidal, engage her in discussion about your observations. If you suspect she may be at risk of suicide, let her know that you are concerned about her and are willing to help.
Ask Carla directly about suicidal thoughts.
Do not avoid using the word ‘suicide’.
Ask the question without expressing a negative judgment.
Be direct and to the point.
ACTIVITY: Asking Carla if she is suicidal.
Question: If you are thinking that Carla may be suicidal, which of the following questions are suitable to ask her?
We will differentiate between the right and wrong tgings to say.
RIGHT
It might be something that’s hard to talk about, but I’m worried about you. Are you having thoughts of suicide?
Are you thinking about killing yourself?
WRONG
You’re not thinking of doing something stupid are you?
A friend of mine committed suicide. You’d never do that would you?
Someone like you would never consider suicide…would you?
You’re not thinking about taking your own life are you? Think about what that would do to your family.
Safety concerns
If the person says ‘Yes, I am thinking of suicide’, you need to act quickly to help keep them safe.
Key points:
A person who is suicidal should not be left on their own. If you suspect there is an immediate risk of the person acting on suicidal thoughts, act quickly, even if you are unsure. Work collaboratively with the suicidal person to ensure their safety, rather than acting alone to prevent suicide.
Remind the suicidal person that suicidal thoughts need not be acted on. Reassure the suicidal person that there are solutions to problems or ways of coping other than suicide.
Find out who or what has supported the person in the past and whether these supports are still available.
Ask them how they would like to be supported and if there is anything you can do to help.
Although you can offer support, you are not responsible for the actions or behaviours of someone else, and cannot control what they might decide to do.
For information about suicide helplines, contact the Seafarers Association.
What about professional help?
Encourage the person to get appropriate professional help as soon as possible.
Find out information about the resources and services available for a person who is considering suicide, including local services that can assist in response to people at risk of suicide such as hospitals, mental health clinics, mobile outreach crisis teams, suicide prevention helplines and local emergency services.
Provide this information to the suicidal person and discuss help-seeking options with them.
If they don’t want to talk to someone face-to-face, encourage them to contact a suicide helpline, or Pastor Ken & the Seafarers.
WHAT TO DO:
If the suicidal person is reluctant to seek help, keep encouraging them to see a mental health professional and contact a suicide prevention hotline for guidance on how to help them.
If the suicidal person refuses professional help, call a mental health centre or crisis telephone line and ask for advice on the situation.
If you believe the suicidal person will not stay safe, seek their permission to contact their regular doctor or mental health professional about your concerns.
If the person has a specific plan for suicide, or if they have the means to carry out their suicide plan, call a mental health centre or crisis telephone line and ask for advice on the situation.
If the suicidal person has a weapon, contact the police. When contacting the police, inform them that the person is suicidal to help them respond appropriately. Make sure you do not put yourself in any danger while offering support to the suicidal person.
Be prepared for the suicidal person to possibly express anger and feel betrayed by your attempt to prevent their suicide or help them get professional help. Try not to take personally any hurtful actions or words of the suicidal person.
What should I talk about with a suicidal person?
People will usually be honest if they are suicidal because in most cases they don’t really want to die. Instead, they want their pain to end. If they think you can help, they will probably speak honestly with you. If you appear confident in the face of the suicide crisis, this can be reassuring for the suicidal person.
Ask the suicidal person what they are thinking and feeling. Reassure them that you want to hear whatever they have to say. Allow them to talk about these thoughts and feelings, and their reasons for wanting to die and acknowledge these. Let the suicidal person know it is okay to talk about things that might be painful, even if it is hard. Allow them to express their feelings (e.g. allow them to cry, express anger, or scream). A suicidal person may feel relief at being able to do so.
WRONG
Other people are worse off than you.
You’ll ruin the lives of your friends and family.
It’s just a bad day, you’ll get over it.
RIGHT
Suicidal thoughts are often a result of a mental illness that can be treated.
I care and I want to help you.
You’re feeling really bad right now, but you won’t always feel this bad. I know you do not think so at the moment, but things will get better.
Suicide key actions
Summary of key actions
You have covered a lot of material about suicide in this module and may be finding it overwhelming. Remember you can review the material any time.
It can be useful to keep in mind the following three actions. If you can remember little else, these actions can be enough to save a life.
If you think someone may be suicidal, ask them.
If they say ‘yes’, do not leave them alone.
Link them with professional help.
A final note
Do your best for the person you are trying to help.
However, you should remember that despite a first aider’s best efforts, some people will still die by suicide.
This is a difficult topic and it has been quite challenging to summon the courage to make the space for it in yachting, I believe education is crucial. We can only begin to understand these issues though accurate education & making space for Mental Health issues in yachting.
Amanda Beaver, MSOS Trainer & Nurse
