Depression, Divorce and Mental Health – A Brief Overview

Dr Russell Foster
Consultant Psychiatrist

Throughout life things change, unfortunately not always for the best.

While some changes are usually considered good, such as getting through the last day of school, winning the lottery or the start of the summer, life does not always go the way we want it to.

This has given rise to the notion of’ life events’, which can affect us in many different ways.

Among the more stressful life events is that of divorce, which for most people will invoke a number of thoughts, feelings and ideas, most of which are unlikely to be positive.

Indeed, divorce has myriad impacts and connotations, with a key one being its impact on those directly involved, including friends and family. Not surprisingly, divorce can result in mental health problems.

This article aims to address the following key questions, albeit in brief detail:

  1. How can I tell if I’m depressed (symptoms) as opposed to feeling low due to my divorce? (Difference between grief and depression)?
  2. What treatment options are there for depression and when is it advisable to see a doctor?

Stress

Divorce, like many life events is stressful, with stress being one of those terms that we all use and seem to understand, but the term does have a number of meanings and impacts, and not all stress is bad, although obviously this is somewhat subjective. Here is a definition of stress: “An uncomfortable “emotional experience accompanied by predictable biochemical, physiological and behavioral changes”. [1] It is likely that applying this definition to divorce will not result in too much disagreement, and it is clear that stress and mental disorders can and do have links.

 

Grief versus Depression

So, How can I tell if I’m depressed as opposed to feeling low due to my divorce? In other words, what is the difference between grief and depression?

This question is rather complex, given that what in commonly referred to grief and depression are interpreted differently by psychiatrists.

Let’s start with grief; this is a normal human reaction to certain events, namely some sort of loss.

It is associated with a range of emotions, thoughts, feelings, actions, responses and outcomes and many theories have been proposed to explain it. Like most human experiences it is perhaps better thought of as a process rather than as a single ‘thing’, and thus its impact will depend on the individual in question with different people reacting in different ways.

A key theory of grief, that was proposed by Kubler-Ross, [2] suggests that it comprises of 5 stages (denial, anger, bargaining, depression and acceptance).

George Bonanno, an American professor of Psychology [3] identified four ‘trajectories’ (outcomes) of grief (resilience, recovery, chronic dysfunction, delayed grief or trauma) and suggests that it is an absence of symptoms which is the desired outcome and that resilience is an innate human ability that cannot be taught.

How true this is remains subject to debate and further research.

Adjustment Disorder

There are many diagnoses in psychiatry, and the diagnosis of adjustment disorder is applied to the reaction to a stressful life event such as divorce.

Here are the diagnostic criteria for adjustment disorder according to one of the main diagnostic classification systems currently in use, the DSM-5: [4]

  1. Emotional or behavioral symptoms develop in response to an identifiable stressor or stressors within three months of the onset of the stressor(s);
  2. The symptoms or behaviors are clinically significant, as evidenced by one or both of the following: (a) marked distress that is out of proportion to the severity or intensity of the stressor, even when external context and cultural factors that might influence symptom severity and presentation are taken into account; and (b) significant impairment in social, occupational, or other areas of functioning;
  3. The stress-related disturbance does not meet criteria for another mental disorder and is not merely an exacerbation of a preexisting mental disorder;
  4. The symptoms do not represent normal bereavement;
  5. After the termination of the stressor (or its consequences), the symptoms persist for no longer than an additional 6 months;

Additionally, six sub-types have been described in the DSM-5:

  1. With depressed mood – characterized by symptoms of depression such as low mood, loss of motivation and reduced enjoyment of normally enjoyable activities;
  2. With anxious mood – characterised by symptoms of anxiety such as worry, overestimation of negative possibilities, helplessness or feeling overwhelmed;
  3. With mixed anxiety and depressed mood – characterized by symptoms of both depression and anxiety
  4. With disturbance of conduct or behaviors that violate the rights of others or may be socially unacceptable such as binge eating, excessive drinking or drug use, outbursts of anger, efforts to punish or seek revenge on others;
  5. With mixed disturbance of emotions and conduct presenting with a combination of emotional symptoms (such as depressive or anxious) and conduct disturbances;
  6. Unspecified – Theses are maladaptive reactions to stress that do not fall into any other subtype;

Note that adjustment disorders are usually short-lived, do not include more severe ‘psychotic’ symptoms such as hearing voices, delusions and so forth, and also exclude other psychiatric disorders. Here it is helpful to contrast adjustment disorder with what is commonly termed depression. Most people equate depression with low mood, but is a range of other, associated symptoms, and to complicate matters there are a range of similar disorders which will not be discussed here.

Depression

Most people will be acquainted with the idea of depression, but in reality this is just a word and in mental health circles there are a wide range of descriptions of this concept.

For the sake of simplicity, only the details of what is arguably the main type of depressive presentation, termed ‘depressive episode’, will be presented, as depressive disorders, also called ‘mood’ or ‘affective’ disorders constitute a complex range of disorders. Here are the diagnostic criteria for a depressive episode: [5]

Depressed mood, loss of interest and enjoyment, and reduced energy leading to increased fatiguability and diminished activity. Marked tiredness after only slight effort is common. Other common symptoms are:

(a) reduced concentration and attention;

(b) reduced self-esteem and self-confidence;

(c) ideas of guilt and unworthiness (even in a mild type of episode);

(d) bleak and pessimistic views of the future;

(e) ideas or acts of self-harm or suicide;

(f) disturbed sleep

(g) diminished appetite.

Any lowered mood usually shows little variation from day to day, but may show variation as the day goes on.  The clinical presentation shows marked individual variations, and in some cases, anxiety, distress, and motor agitation may be more prominent at times than the depression.

There may also be other features such as irritability, excessive consumption of alcohol, histrionic behaviour, exacerbation of pre-existing phobic or obsessional symptoms, or by preoccupations (of having a physical serious illness.

A duration of at least 2 weeks is usually required for diagnosis, but the diagnosis may be made with shorter durations is symptoms are especially severe and of rapid onset.

A number of other symptoms may also be present:

-loss of interest or pleasure in activities that are normally enjoyable;

-lack of emotional reactivity to normally pleasurable surroundings and events;

-waking in the morning 2 hours or more before the usual time;

-depression worse in the morning;

-objective evidence of definite psychomotor retardation or agitation (that is, undertaking activities or functioning more slowly or always being on the go) which is remarked on or reported by other people);

-marked loss of appetite;

-weight loss (often defined as 5% or more of body weight in the past month);

-marked loss of libido.

Note that these symptoms can overlap with other mental health disorders as well as physical health disorders and can be classed as mild, moderate or severe depending on several factors such as number and severity of symptoms.

 

Treatment of Depression

If you ask a doctor about treatments for any condition, especially one who has a good background in treatment of mental health disorders, they may well reply with the cryptic reply of Biological, Psychological and Social.

In other words, treatments are divided into three main types, which I will now explain in brief detail.

Biological Treatments

This category includes ‘physical’ treatments, which are perhaps the most commonly recognized by most people.

The mainstay of biological treatment in depression is medication, of which there are many examples, with new medications being introduced every so often. Prescribing for depression is complicated, with different medications prescribed for different presentations.

Not all people respond to medication and prescribing needs to take in a large number of individual variables. There are several classes of anti-depressants depending on their mode of action, and ant-depressants can be used for other conditions apart from depression, including some other mental health conditions as well as physical conditions such as pain and even incontinence.

Commonly used anti-depressants include:

 

Class Example Brand Name
Selective serotonin reuptake inhibitors (SSRIs)

 

Fluoxetine Prozac
Citalopram Cipramil
Paroxetine Seroxat
Sertraline Lustral
Serotonin-noradrenaline reuptake inhibitors (SNRIs)

 

Duloxetine Cymbalta
Venlafaxine Efexor
Noradrenaline and specific serotonergic antidepressants (NASSAs)

 

Mirtazepine Zispin
Tricyclic antidepressants (TCAs)

 

Amitriptyline Tryptizol
Clomipramine Anafranil

 

Apart from medications other biological treatments include ECT (Electroconvulsive therapy), in which a mild electric shock is given to the anaesthetised patient to induce a mild seizure and Transcranial Magnetic Stimulation therapy (TMS) in which a wand is placed over the head of the patient and electric currents are generated which are thought to stimulate specific brains areas.

Brain surgery is a final example of biological treatment, but this is extremely rarely performed and is not generally considered in the treatment of depressive disorders.

 

Psychological Treatments

These comprise ‘talking’ therapies, with most people understanding these as some form of ‘counselling’.

This is not quite accurate, as counselling, itself comprising several approaches, differs from the mainstay of psychological therapy, namely Cognitive Behavioural Therapy (CBT).

Counselling involves talking about problems to a counselor, with the view to providing support but not advice. Rather, the aim is to assist the client in their own understanding of the problems and to gaining their own insights.

CBT aims to help by showing the interconnections between thoughts, feelings, physical sensations and behaviours/actions with the aim of helping the client to understand these interconnections and how to change them.

It addresses current problems rather than past events and is a highly structured form of treatment that requires he individual to be motivated and committed. It entails a series of sessions, usually weekly, with ‘homework’ to apply ideas and newly acquired skills.

There are may other different types of talking therapies, but in the case of divorce it is likely counselling that would be the most commonly used first-line talking therapy.

 

Social treatments

Finally, social treatments need to be considered, which include having good social support, somewhere to live, food to eat, financial stability, some sort of structured activity such as work, hobbies, regular physical activity and so on.

Without these other treatments may be less effective, and the usual approach at lest in NHS mental health care is to consider all relevant aspects of an individual’s presentation so as to provide the optimal treatment that aims for long-term stability.

 

When to seek help

It can be difficult to know when to speak to your doctor about any sort of health problem, and often the thought of doing this is worse than the reality when and if it actually happens.

If you feel, or someone else feels, that there is a problem which is having an impact on your functioning, it is worth seeing your GP, not least for peace of mind. Your GP will then be able to advise what the next step is.

It is possible to self-refer to some mental health services such as IAPT (‘Improving Access to Psychological therapies’), and your GP can often advise re other interventions or services which may be appropriate. If in doubt speak to your GP, a trusted friend, a family member, and if necessary ask them to go with you to the GP.

Most people undergoing life events do not need to see a psychiatrist, and those that do will more often than not benefit from this. There is help and support out there, and often taking the first step to access this is the hardest…

[1] Baum A (1990) “Stress, Intrusive Imagery, and Chronic Distress” Health Psychology 6: 653-675.

[2] Kubler-Ross E (1969) On death and dying. New York: Macmillan.

[3] Bonanno GA (2004) “Loss, Trauma, and Human Resilience: Have We Underestimated the Human Capacity to Thrive After Extremely Aversive Events?” American Psychologist 59 (1): 20–8.

[4] American Psychiatric Association (2013) Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. 5th. Arlington, VA: American Psychiatric Association; 2013.

[5] World Health Organisation (1992) ICD-10 Classifications of Mental and Behavioural Disorder: Clinical Descriptions and Diagnostic Guidelines. Geneva: World Health Organisation.

About Dr Foster

Russell is Albert Square Mediation Limited‘s consultant on medical related issues.

He is a distinguished consultant liaison psychiatrist and specialist in liver transplant psychiatry, a member of the Judiciary, Responsible Officer in a top 100 company  and an acknowledged expert in his field.

He is a very widely published author and speaks a number of languages. Having lived in Canada, North Africa and Norway and travelled extensively he brings an international perspective to his career.

His experiences of working in the NHS have drawn him to the conclusion that the current adversarial models such as internal discipline proceedings and court related litigation that are often used to resolve medical related disputes are ineffective and are a massive burden on the public finances.

Apart from postgraduate qualifications in medicine, psychiatry, biochemistry, toxicology, law and others Russell also has training in workplace mediation and healthcare management.

He also has an interest in what the mediation process can offer healthcare professions in the UK. His primary role is  to assist ASM in promoting its medical mediation work and where appropriate he will give informal guidance.

Outside of work he enjoys cycle training, travelling, composing music and learning new languages.

See Russell Foster’s LinkedIn profile here

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