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1. Depressive disorders
 
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1. Depressive disorders
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About depressive disorders

Major depression is characterised by a persistently low mood and/or a loss of interest or pleasure in activities. In addition, the depressed veteran may experience a number of additional symptoms including:

  • changes in appetite and/or weight
  • insomnia or hypersomnia
  • psychomotor agitation or retardation
  • low energy or fatigue
  • trouble concentrating or making decisions
  • feelings of worthlessness or excessive guilt
  • recurrent thoughts of death or suicidal thoughts or behaviour.

It is important to remember that depressed individuals will not necessarily present with a primary complaint of depression. Many will seek help for insomnia, or pain, or appear excessively worried about physical aches and pains. Veterans may complain of feeling irritable, sad, or having no feelings at all. In assessing the presence of depression, clinicians should take note of facial expressions and general demeanour in addition to the person’s self-reported symptoms. For a diagnosis of major depression, symptoms must be present for most of the day and/or nearly every day, for at least two weeks, and represent a significant departure from normal functioning. Depression can range from mild to severe, and may become chronic, relapse, or less commonly, occur as part of a bipolar mood disorder.

Some people will experience consistent feelings of low mood for two years or more, but not have symptoms severe enough to be diagnosed with major depression. This condition has traditionally been known as dysthymia and is relatively common in veterans. In DSM-5, dysthymia and chronic major depression are combined in a new diagnosis called Persistent Depressive Disorder.

Approximately 15 percent of Australians will experience a depressive disorder (i.e., major depression or dysthymia) at least once in their lifetime (Australian Bureau of Statistics, 2007). These disorders (particularly chronic forms of depression) are also common in veteran populations, although prevalence rates differ across deployments. For example, depressive disorders affect around 26 percent of Vietnam veterans (O'Toole et al., 1996) and 32 per cent of Gulf war veterans (Black et al., 2004).

A number of factors place veterans at increased risk of depression, including military-specific factors such as war-related traumatic events, discharge and the transition to civilian life, and more generic stressors such as marital breakdown. As in the general population, female veterans are at greater risk of developing depressive symptoms than males. It is worth keeping this in mind given the increasing proportion of women in the younger cohort of veterans.

Screening and assessment

Screening questions for depression should include the use of at least two questions concerning mood and interest. The following questions are recommended in the United Kingdom’s National Institute for Health and Care Excellence (NICE) guidelines (2009):

  • During the last month, have you often been bothered by feeling down, depressed, or hopeless?
  • During the last month, have you often been bothered by having little interest or pleasure in doing things?

If the veteran answers ‘yes’ to either of these questions, further assessment of their mental state and associated social, occupational, and interpersonal difficulties should be conducted.

A number of self-report measures are available to assess the severity of depressive symptoms. These include the:

  • Depression Anxiety and Stress Scale (DASS-21; Lovibond & Lovibond, 1995). This can be used to help track depressive symptoms as well as counselling outcomes. See Appendix C or www.at-ease.dva.gov.au for the measure, administration, scoring and interpretation instructions)
  • Hamilton Depression Scale (HAM-D; Hamilton, 1960)
  • Beck Depression Inventory (BDI-II; Beck, Steer & Brown, 1996)
  • Hospital Anxiety and Depression Scale (HADS; Zigmond & Snaith, 1983)

Risk assessment – self-harm/suicide and harm to others

Depression is a significant risk factor for suicide. Veterans who are assessed as having depression should be screened using direct and unambiguous questions such as:

  • Are there times when things seem so hopeless that you think about killing yourself?
  • (If yes), do you have a plan of how you might do this?
  • (If yes), do you have access to … (check means and opportunity)?
  • Have you ever harmed yourself or tried to kill yourself in the past?
  • Do you live alone (or unsupervised)?
  • Do you use amphetamines, alcohol, or other substances?

The above questions can be reframed to assess risk of harm to others, e.g., “Are there times when things seem so hopeless that you think about ending the lives of others around you?”

Be aware that many symptoms of depression, such as lack of motivation, psychomotor retardation, and apathy initially reduce the risk of suicide and harm to others. However, practitioners should be alert to the risk of harm to self or others as clients start to recover; they may still feel hopeless, but have regained enough energy to act on suicidal or homicidal thoughts.

Where there are issues of potential harm to self or others, practitioners should be aware of their duty of care to both the veteran and others, as set down by the ethical standards established by their professional group.

Veterans with depressive disorders may have fluctuating or continued severe distress and significant potential for self-harm. For a portion of veterans, particularly younger veterans, impulsive self-destructive and aggressive behaviours such as dangerous driving are common.
 

Treatment

Self-help

Cognitive behavioural therapy (CBT) is the self-help treatment of choice for depression. A guided self-help program based on CBT is appropriate for veterans with mild depression. Examples of such programs include publications such as Mind over mood: A cognitive therapy treatment manual for clients (Padesky and Greenberger, 1995) and Feeling good: The new mood therapy (Burns, 2008). There are also several excellent internet based self-help programs (e.g., MoodGYM www.moodgym.anu.edu.au), which have been found to reduce symptoms of depression and dysfunctional thinking in members of the general population (Christensen, Griffiths, & Jorm, 2004). There are also written materials for veterans and their families available from websites such as those included under ‘Self-management resources’ (later in this chapter).

Psychological intervention

Cognitive behavioural therapy

Mental health practitioner-delivered CBT should be considered for veterans with moderate or severe depression. Talking to a veteran, together with the veteran’s family, about his or her depression is the start of treatment. A summary of useful information to be conveyed to the veteran and his or her family is included in the following text box.

Psychoeducation and self-management strategies

When providing psychoeducation it is important to explain and demystify the veteran’s symptoms, and to help the veteran regain a sense of control and a sense of hope. It is also important to encourage the veteran to do the following:

  • Prioritise spending time and reconnecting with their social supports, e.g., sympathetic family members and friends, local interpersonal community activities. There is strong evidence that social support is a key factor in preventing deterioration of symptoms and in promoting recovery.
  • Maintain (or re-establish) their daily routine and current roles (e.g., work, family). This is particularly important for veterans who have a lot of unstructured time or have prominent or long-standing avoidance symptoms. This may include starting an exercise routine (as simple as a daily 20 minute walk) and engaging in planned pleasant events.
  • Reduce substance use. While alcohol and drugs may alleviate distress in the short term, they inhibit recovery. This is a significant issue amongst veterans, with high comorbidity between depression and substance use issues. Early advice on reducing substance use is effective.

Whilst CBT has some general techniques applicable across a range of disorders, specific CBT techniques for targeting depression are:

  • Structured problem solving – This can help the veteran address feared problems that they otherwise might find overwhelming.
  • Activity scheduling – This involves scheduling a balance of pleasant, achievement-related and physical activities. It assists with circumventing rumination, and increases positive and rewarding experiences thereby targeting symptoms such as low motivation and mood, lack of energy and withdrawal from activities and people.
  • Cognitive therapy – This assists in identifying and challenging excessively negative thoughts about oneself, one’s future, or the loss of a loved one or something highly valued. The veteran learns to challenge the accuracy of those thoughts and identify more balanced and helpful interpretations of events, and perceptions of themselves, others and the world.

Interpersonal therapy

People with depression can be easily upset by other people’s comments, and experience significant interpersonal difficulties that contribute to or exacerbate depression. Interpersonal therapy (IPT) aims to help the veteran understand and resolve these difficulties. IPT has been less thoroughly researched than CBT, but evidence so far suggests that the two therapies are broadly similar in terms of effectiveness (Cuijpers et al., 2011). Therefore, the decision to progress with one over the other will come down to the preferences of both the veteran and practitioner.

Mindfulness-based interventions

Mindfulness-based interventions aim to increase self-awareness and teach veterans to have distance from their thoughts and emotions so that unpleasant events cause less distress. It is thought that with less emotional investment, the potential for extreme negative reactions such as depression is limited. While mindfulness-based therapies are widely practised, they have been less thoroughly researched. These therapies appear to be more effective than placebo interventions (Hofmann, Sawyer, Witt, & Oh, 2010), but it is not clear how they compare with established treatments for depression such as CBT or IPT. Therefore, at this stage it is recommended that mindfulness approaches be considered only for individuals whose depression has not responded to CBT or IPT.

Psychological treatment setting and duration

Mild to moderate depression can be treated in an outpatient setting and does not usually require admission to a psychiatric hospital unit. Requirements for admission depend on the severity of depression and the risk of self-harm and suicide. Psychological treatment for mild to moderate depression should focus specifically on the depression for a period of 6-8 sessions over 10-12 weeks. In more difficult and complex cases, a longer course of psychological treatment may be required.

Pharmacological interventions

Medication is usually not recommended for mild depression, in preference to psychological interventions. Antidepressants may be considered for veterans with moderate or severe depression, adjunctive to or followed by psychotherapy. Selective serotonin reuptake inhibitors (SSRIs) are recommended as the first line of pharmacotherapy. Older-generation antidepressants such as the tricyclics (e.g. Deptram) may be more effective in treating severe or treatment-resistant depression but pose a greater risk of overdose and should be prescribed with caution.

Electroconvulsive therapy

Electroconvulsive therapy (ECT) remains an important antidepressant treatment. It is used mainly in the context of severe depression (characterised by melancholia, psychotic features and/or high suicide risk) and it is only to be administered in a psychiatric setting with accredited facilities and practitioners. There are some medical contraindications to ECT and the general anaesthetic that it requires.

When effective, ECT provides short-term improvement. Subsequent maintenance antidepressant medication is usually required. Cognitive impairment for a time around the treatment is a side effect of ECT, but there is no objective evidence of it persisting after a course of treatment. Maintenance ECT has not been well researched, but is used on occasions where medications and psychotherapy have failed as maintenance treatments. The decision to use ECT should be taken only after careful clinical review, and documented, informed consent is given.
 

Referral and coordinated care

  • VVCS - Veterans and Veterans Families Counselling Service (VVCS): This service provides veterans and their families with counselling and group programs Australia-wide. VVCS can be contacted 24 hours a day on 1800 011 046. (www.vvcs.gov.au)
  • Psychiatrist: for specialist management of more severe, chronic or complex problems. Some psychiatrists specialise in psychological treatments; they can review or prescribe medication, provide diagnoses, and manage co-occurring physical health problems. Allied health providers should liaise with GPs to arrange a referral. GPs can access a list of private psychiatrists at http://www.ranzcp.org/Resources/find-a-psychiatrist.aspx.
  • If hospitalisation is required, there are veteran specific mental health wards and treatment programs. To find out their location, phone DVA on 133 254 or 1800 555 254.
  • A treatment plan should be developed collaboratively with the veteran and their family, and coordinated across service providers.
  • Consider psychosocial and/or vocational rehabilitation services from the beginning of treatment. DVA can offer extensive rehabilitation services for entitled veterans (www.dva.gov.au/rehabilitation).

 

Self-management resources

  • Veterans Line (1800 011 046) can be reached 24 hours a day across Australia for crisis support and counselling. This service is provided by VVCS.
  • The At Ease portal (www.at-ease.dva.gov.au) contains mental health and wellbeing resources, including websites, mobile apps and information booklets for both veterans and clinicians.
  • The Royal Australian & New Zealand College of Psychiatrists (2009). Coping with depression: Australian treatment guide for consumers and carers. Download from www.ranzcp.org/Publications/Clinical-Practice-Guidelines-2.aspx.
  • Written materials for clients and their families are available from websites such as beyondblue (www.beyondblue.org.au), Black Dog Institute (www.blackdoginstitute.org.au), and the Australian Psychological Society (www.psychology.org.au).
  • Internet based self-help programs, e.g., MoodGYM (www.moodgym.anu.edu.au).
  • Self-help books include Greenberger & Padesky (1995), Mind over Mood: A cognitive therapy treatment manual for clients, and Burns (2008), Feeling good: The new mood therapy.

 

Practitioner resources

  • Padesky, C. & Greenberger, D. (1995). Clinician’s guide to mind over mood. Guildford Press: New York.
  • Beck, A.T., Rush, A.J., Shaw, B.F. & Emery, G. (1987). Cognitive therapy of depression. Guilford Press: New York.

This Advice Book has the following resources in the appendices that may be useful for veterans who are experiencing depressive symptoms:

  • further explanation of CBT elements (Appendix B)
  • veteran psychoeducation handout and general psychoeducation script outline (Appendix D & Appendix L)
  • self-monitoring sheets including thoughts and feelings records and a daily activity schedule (Appendix E)
  • pleasant events list (Appendix F)
  • information on where veterans can get more help, e.g., Veterans Line, DVA funded psychological and rehabilitation services (Appendix J).