Mental Health

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mental-health

Depression

We all feel sad or get "the blues" now and again. And we may feel sad and depressed following the death of a loved one or the breakup of a love relationship. Generally our sadness lessens in time and with the support of friends. However, if the depression leads to difficulty in thinking, greatly disrupts a person's daily routine, and persists with no symptom relief, it can be evidence of a serious psychiatric problem.

Changes in mood characterized by feelings of sadness, pessimism, guilt, hopelessness and worthlessness may be caused by normal sadness resulting from a loss, chronic low self-esteem and limited self-confidence, a reaction to a medication or drug, prolonged stress, major depression, or biposal depressive illness or a complication of another psychiatric illness or medical condition. Thyroid dysfunction, for example, can cause symptoms that mimic depression.

Depression may occur as a result of biochemical changes in the body. Alcohol, amphetamines, cocaine, and LSD can bring on depression or worsen an existing depression. Some people have a greater risk of depression, such as those who have a family history of depression, or who have gone through a major loss of losses (death, economic failure, dimished social status, etc.). Persons with "perfectionistic personality," persons who suppress their emotions, persons who are more passive, dependent, or pessimistic in attitudes, and persons who abuse alcohol or other drugs are also at higher risk for experiencing depression. So too are women, survivors of sexual or physical abuse, and adolescents.

The exact causes of depression are not completely understood, but research on psychotherapy for mood disorders is expanding, and new medications are introduced every year as our knowledge of the neurophysiological basis of disturbed mood and its relation to other states of mind and body are explored.

What are the symptoms?

The symptoms of depression include the following:

feeling sad, "blue," or "empty"
experiencing crying spells, anxiety, agitation, restlessness, or irritability
changes in appetite and/or weight
changes in sleep patterns such as insomnia, early awakening, or an increase in time spent sleeping
fatigue or loss of energy
loss of interest or pleasure in usual activities
feelings of self-reproach, inappropriate guilt, or worthlessness
difficulty in thinking clearly, or in concentration
thoughts of suicide or death

Personality changes are common because of the psychological stress on the depressed person. Depressed people often have difficulty in maintaining normal relationships with others, and they may withdraw socially.

How is it diagnosed?

Depression can be diagnosed by a health care provider. Your provider will discuss with you your symptoms, your personal history, and a physical examination and laboratory studies may be performed to rule out a physical cause for your symptoms. Generally, if you have experienced five of the symptoms listed above most of the day, nearly every day for at least two weeks, a diagnosis of depression would be considered. Criteria for the American Psychiatric Association's Diagnostic and Statistical Manual, DSM-IV (1994), are used to classify mood disorders for purposes of research and choice of treatment.

How is it treated?

Since major depression and its milder chronic form, dysthymia, can interfere with clear thinking it is unwise to try to overcome depression by yourself. Fewer than half of the people with mood disorders receive treatment. In some cases, they do not seek treatment because of fear of social stigma, fears about confidentiality, a sense of hopelessness, or due to incorrect diagnosis. The standards treatments for depression are psychotherapy, antidepressant medication, or a combination of both. Depression can generally be treated on an outpatient basis, with hospitalization only necessary when a danger to self (suicide) or others exists, when your living environment contributes to your depression, or when you cannot carry out the activities of daily living by yourself.

Psychotherapy can give you support and help you regain control. One approach to treating depression is called "cognitive-behavioral therapy," which usually lasts 12 to 20 weeks. During counseling sessions, the therapist will help you identify unrealistic views you may hold of yourself, the world, and the future. Therapy will help you recognize depressive thought processes and develop thought and behavior patterns that counteract depressive thought.
Another form of psychotherapy is directed at helping you gain insight and understanding about events in your life which may have contributed to your depression. With growing insight you can often learn more effective ways of coping with your feelings and changing your behavior.

Antidepressant medications are often used to treat depression, sometimes in combination with psychotherapy. Although many different drugs can be used, there are three main classes of antidepressants: tricyclics (TCAs), which alter the brain's response to neurotransmitters norepinephrine and serotonin; monoamine oxidase inhibitors (MAOIs), which block the action of an enzyme that breaks down the transmitters norepinephrine and dopamine; and the most recent addition, selective serotonin reuptake inhibitors (SSRIs), which enhance the activity of the neurotransmitter serotonin by preventing its reabsorption at nerve endings.

TCAs and MAOIs were the first antidepressants available and for years they were the most widely prescribed. Their use is still common but slowly declining because of side effects and the availability of alternatives.

SSRIs such as Prozac (fluoxetine), Zoloft (sertraline), and Paxil (paroxetine) have gained increasing populatiry and use because of effective results with minimal side effects. What is reliably known about SSRIs is neither as exciting nor as frightening as some of the publicity suggests. Expect possibly in the most severe depressions, they are as effective as TCAs, with fewer side effects that may otherwise cause patients to discontinue their use.

Antidepressant medications often take several weeks to begin working, and must be taken long enough to stop the symptoms of depression, usually 3-6 months. It usually takes 2 to 4 weeks following the start of medication before you start to feel better. These medications do have side effects which will be reviewed with you by your health care provider.

How long will the effects of depression last?

Most depression ends spontaneously in 3 to 6 months. A combination of psychotherapy and antidepressant medication should help you feel better in a few weeks. However, sometimes depression is a recurring problem. If symptoms of depression return, call your therapist or health care provider immediately.

How can I take care of myself?

Follow the treatment recommended by your health care provider, including antidepressant medication (if prescribed) and counseling. In addition, you can:

Join a support group.
Express your feelings through talk, journaling, or even art.
Participate in activities even when it may be difficult to do so.
Exercise on a regular basis.
Do something special just for yourself (when you feel like you deserve it the least is when you need it the most!)
Get adequate rest.
Eat nutritious, well-balanced meals
Call for help IMMEDIATELY if you feel suicidal or are having thoughts of suicide or death.

Certain medications and alcohol can add to the symptoms of depression. If you have been or are being treated for depression, it is important to check with your provider before taking any new medications, either over-the-counter or prescribed by other providers. For example, patients taking an SSRI should not use an over-the-counter cough syrup that contains dextromethorphan, a common ingredient in many cough syrups.

What can be done to help prevent depression?

Remember "Mom's advice:" eat nutritious meals, get plenty of rest, and exercise at least 3 times a week. Find a hobby or a positive recreational activity to participate in once or twice a week. Talk to your friends or a support group about what you are feeling. Laugh. Reduce caffeine and alcohol intake. Develop and maintain a positive attitude. Learn how to manage the stress in your life. Ask for help if the load is too heavy to handle. And seek professional help for talking about events in your life that cause you to feel anxious or depressed and developing positive ways to cope with problems.

Rolffs S. Pinkerton, Ph.D.;

Rev. 8/03

Perfectionism

What is perfectionism?

Perfectionism is the propensity to generate debilitating emotions and unproductive behavior by setting unrealistic high standards for one's performance, rigidly adhering to these standards, and equating self-worth with one's performance.

Perfectionism occurs in a number of forms which fall on a continuum of the degree to which it is disruptive to an individual. At the more benign end, many who are serious about performing well entertain perfectionistic thoughts on occasion and find themselves worrying unnecessarily, procrastinating, or second guessing their actions after finalizing an initiative; however, they are able to put these worries aside and attend to their tasks in a relatively effective manner. At the other end of the continuum are those who are continually handicapped by a strongly ingrained perfectionistic trait and suffer considerably in their self-esteem, emotional health and productivity. Midway on the continuum are individuals who waver in the degree to which they can manage their perfectionistic demands.

It is common for university students to go through a phase of difficulty with perfectionism as they make the transition from high school and home to college-level demands.

What are the indicators of difficulty with perfectionism?

Perfectionistic thinking is relatively common, particularly in a competitive university environment like Duke. With most people, perfectionistic struggles are manageable, minor difficulties. More pronounced difficulties with perfectionism can show up in a number of forms:

extensive procrastination, because the person cannot free her/himself from perfectionistic demands long enough to begin writing, studying, etc.
heightened anxiety caused by perfectionistic "what if-ing" about upcoming events (tests, speeches, dates, etc.), which can lead to blanking (such as on tests) and concentration lapses high stress levels and fatigue caused by worrying incessantly about performance and adequacy
depressed mood due to perfectionistic beating up on oneself when one's performance falls beneath one's rigid expectations
lack of enjoyment in life, because perfectionism prevents one from enjoying rewards and leisure when there are any unjumped hurdles to contemplate (and there always are)

What can be done to overcome perfectionism?

The first step in addressing your perfectionistic tendencies is to assess the level of your difficulty by considering the following questions:

Do you engage in dichotomous, right-wrong thinking?
Do you construe your goals as necessities for feeling good about yourself more than as achievements that would be desirable but not necessary?
Do you tend to worry about undone tasks in the future without giving yourself credit for feeling relief for tasks you have completed?
Do you selectively attend to your mistakes and overlook your successes?
Do your feelings of self-worth go up and down with your judgment of how well you have performed?

If you answered "yes" to several of these questions, perfectionism is probably a relatively strong trait for you, particularly if some of the indicators of perfectionistic difficulty described above are present. Make an appointment to talk with a counselor to further assess your difficulty and discuss how it can best be addressed.

If you answered "no" or "sort of" rather than a bold "yes" to most questions, you can probably enhance the degree to which you manage perfectionistic thinking by consciously monitoring and re-thinking your thought patterns and applying some of the preventive strategies listed below.

Most people can reach improved levels of self-understanding and self-acceptance and can fashion effective strategies for successfully managing perfectionistic thinking.

How long will the effects last?

In many cases, mild to moderately severe perfectionism can be overcome in short-term therapy. If the trait is unusually stubborn or part of a more involved psychological syndrome or disorder (for example, compulsive personality disorder), the counselor might help you obtain open-ended therapy that is within your financial means. While you might always have perfectionistic tendencies to channel, most people can reach improved levels of self-understanding and self-acceptance and can fashion effective strategies for managing perfectionistic thinking successfully.

What can I do to prevent perfectionism from becoming a problem?

To avoid becoming overwhelmed by perfectionistic thinking, experiment with some of the following strategies:

Begin a conscious campaign to tune into and moderate your perfectionistic thinking.
Monitor your "internal dialogue"--the phrases you mutter or videos you run in your mind. What are your common perfectionistic "mental ruts?" Dichotomous thinking (black-white, categorical classifications)? Catastrophizing (making mountains out of mole hills)? Selective attention (blaming yourself for let-downs but not rewarding yourself for successes)?
Cultivate a more soothing, self-nurturing "coping dialogue" that enables you to be a good friend or good parent to yourself ("I can't do everything perfectly. It's O.K. for me to set priorities and then do the best I can").
Challenge your perfectionistic thought system by purposely experimenting with deviating from it (e.g., resist your tendency to engage in overkill the night before the exam and then see how things work out).
Affirm your humanness by recognizing that your self worth is independent of any single performance.

John Barrow, Ed.D. , rev. 6/03, 12/96

Stress

"Stress is the nonspecific response of the body to any demand made upon it." (Hans Selye, The Stress of Life) In other words, you pay a psychological and physical price when your internal balance is disrupted by a perceived threat, change or transition, and is called upon to adjust. Emotional stress has been likened to the "fight or flight response," in which your body is mobilized for action. A number of physiological changes occur, including increases in muscle tension, heart rate and blood pressure.

What are the effects of stress?

Stress is a normal part of living, and the stress response is helpful in many ways--e.g., motivating you to study or increase your alertness while taking a test or giving a talk. The problem occurs when stress that exceeds a productive level interferes with your ability to think, remember and focus on tasks. Also, stress that is ineffectively managed and remains too high for too long can contribute to physical breakdowns of the body. Examples of medical conditions that are related to stress include heart and circulatory diseases, ulcers, colitis, asthmatic conditions and lowered immunity leading to infectious illnesses.
Stress that is ineffectively managed and remains too high for too long can contribute to physical illnesses.

How does stress occur?

Stress is produced by both normal and unusual events as well as by both positive and negative occurrences. Just as a divorce or a low grade might increase stress, so might positive experiences such as an engagement or admission to graduate school. Because stress can be cumulative, you need to monitor and regulate the number of threats (real or perceived), changes, and transitions that you encounter in the same period of time. Stress can be more harmful when you do not feel in control of your stress levels and the events that produce them.

What are the symptoms of ineffectively managed stress?

Symptoms of stress vary from person to person, but some general signs include:

chronic fatigue
change in appetite
change in bowel or bladder habits
increased irritability
increase in alcohol, drug, or cigarette use
body aches and pains not caused by exercise
change in sleeping or waking patterns
change in behavior or emotional patterns
inability to focus on tasks effectively

How can I take care of myself?

Taking care of yourself starts with recognizing the unhealthy ways of dealing with stress (for example, drinking too much alcohol or eating unhealthfully). You can then try a healthier approach.

How do YOU manage the stress in your life?

You can reduce the negative effects of stress on your life by following these recommendations:
Exercise for 30 minutes at least 3 times a week.
Recognize the things that upset you. When something is increasing your stress, ask yourself, "Is there anything I can do to change the situation?" If there is, figure out what you can do. If there is not, find ways to accept this lack of control.
Develop healthy methods for relaxation; for example, talk with supportive people, listen to music, watch movies, take walks.
Learn to use relaxation techniques, such as mental imaging, diaphragmatic breathing, and progressive muscle relaxation.
Get adequate, regular amounts of rest and sleep (6 to 10 hours a night).
Eat 3 to 6 small, balanced meals a day.
Avoid caffeinated beverages and alcohol.
Drink 4 to 8 glasses of water a day.
Use positive thoughts and humor to overcome negative thoughts.
Identify ways you think yourself into higher levels of stress, including catastrophizing (making mountains out of mole hills), overgeneralizing (jumping to conclusions), dichotomous thinking (right-wrong, good-bad), and perfectionistic thinking ("I'm no good unless I'm perfect"). Then find ways to nudge yourself out of these mental ruts.
Seek professional help for dealing with especially stressful events in your life.

John Barrow, Ed.D., rev. 6/03, 2/96
Related links:
Center for Anxiety and Stress Treatment
Internet Mental Health

Suicide

Suicide is a major problem in American society. Approximately 30,000 people deliberately end their lives each year. Although 15-24 year-olds have a much lower suicide rate than other age groups, the number of suicides among young people has actually tripled in the last 3 decades.

Why do people become suicidal?

There are a number of life circumstances that may cause a person to consider taking his/her own life. During difficult times, people often feel overwhelmed, lonely, hopeless, helpless, worthless, or unloved. These feelings may result from the breakup of a significant relationship, poor academic performance, concerns about sexual orientation, traumatic experiences, or for any number of other reasons. If a person feels overwhelmed by painful feelings and cannot envision a way of obtaining relief, suicide might begin to appear to be a viable escape.

What are suicidal warning signs?

Many individuals who are suicidal express their intent prior to taking their life. It is estimated that 80% of the individuals who kill themselves have communicated their intentions in some way to someone close to them.

The warning signs can be divided into 4 categories (verbal, behavioral, situational, and depressive). None of the signs alone necessarily indicate suicidal potential but several indicators, particularly if it is a change from the person's usual mood or style of coping, may deserve serious attention. The following are some of the warning signs:

Verbal warnings

No verbal statement is too insignificant to let pass without a response. Verbal warnings refer to any verbal response that expresses directly or indirectly a desire not to live, such as:

"I broke up with Bill today; life is no longer worth living."
'They won't have me any more to kick around."
"I am of no use to anyone anymore."
"I can't go on any longer."

Behavioral warnings

failed suicidal attempt
giving away valued possessions
putting affairs in order
alcohol or other substance abuse
withdrawing from activities that previously gave the student satisfaction
crying with no apparent cause
sudden changes in behavior and/or attitude
erratic behavior which cannot be explained
inability or refusal to trust in others
neglect of school work

Situational warnings

Some students may not do or say anything to demonstrate suicide risk but their situations may provide adequate clues. Some of these situations include:

continued family strife
loss of a parent or loved one
experiencing a disfiguring operation or accident
failure to gain admission to a graduate or professional school or program

Depressive warnings

People who seriously consider suicide are very often clinically depressed. Therefore, many of the "warning signs" associated with suicide are also symptoms of clinical depression. These symptoms include:

sleep disturbances (inability to sleep or excessive sleeping)
low self esteem
lack of energy
changes in appetite (loss of or increase in appetite)
evidence of crying
deterioration of personal appearance
withdrawn and preoccupied behavior
difficulty concentrating
feelings of excessive guilt
excessive irritability or frustration
feelings of hopelessness and helplessness
tendency to dwell on problems

Depression in some students is marked by hyperactivity or acting out behavior. If this behavior is different from the way the student usually behaves and if it is combined with other suicidal warning signs, the student may be at risk for suicide.

Suicides sometimes occur after an abrupt lifting of depression. If a person has been depressed for a period of time and then suddenly shows signs of cheerfulness and expresses no signs of depression, it may be an indication that the person has decided to make a suicide attempt.

How can I help?

Trust your instincts that the person may be in trouble
If you suspect the person is suicidal, ask if they have thoughts of suicide.
Ask if they have a plan (have thought about methods) or have the means at hand.
Take all suicidal threats seriously.
Remain calm and understanding.
Be a willing listener.
Ask concerned questions.
Empathize with the student's expression of feelings.
Be reassuring that problems can be solved.
Do not counsel the person yourself. Encourage the student to seek professional help.
Volunteer to accompany the student to a referral agency.
Seek counseling or consultative help for yourself.
Do not leave the person alone.
Do not swear to secrecy.
Do not argue with the person, "You can't kill yourself because..."
Do not offer false assurance or try to "cheer up" the person; many times this comes across as your needing assurances and may cause the other person to feel less accepted and understood.
Do not challenge suicidal remarks "If you feel that bad, go ahead and do it" or "You'll never do anything like that."

If your concerns are immediate and serious, contact help quickly.

Bob James, Ph.D., 12/96

Rev. 7/03, Jeff Kulley, Ph.D.

1. NIMH Suicide Deaths 2000, (2000 Mortality Rate), www.nimh.nih.gov

Student Health Center

Mental Health

Depression

Perfectionism

Stress

Suicide