Wyoming Behavioral Institute

1. Wyoming Behavioral Institute Women and Depression Nadine Dexter, WBI Director of Clinical Services Statewide Videoconference Nov. 13, 2006

2. 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

3. 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

4. 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

5. The “Blues” vs. Depression

6. 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 Grief vs. Depression

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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)

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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

25. 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

26. 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

27. 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

28. 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

29. 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

30. 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

31. 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%),

32. 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%)

33. 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

34. Wyomingites’ Mental Distress

35. Wyomingites’ Mental Distress

36. Wyomingites’ Mental Distress

37. 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%)

38. 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

39. 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

40. 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"

41. 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

42. 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

43. 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

44. 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

45. Wyoming Behavioral Institute • Free, confidential 24 hour toll free assessment hotline: 1-800-457-9312