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Depression in young women: are you equipped to treat it?

Jane Briddon
CQSW BA(Hons)PGDipPsychSW CBTDip
Cognitive ­Behaviour ­Therapist in Primary Care
Coordinator and Lecturer Education, Development and Training Agency
University of Manchester
T:0161 237 2605
E:jane.briddon@man.ac.uk

Many people experience low spells from time to time, but depression is an intense feeling that remains for long periods - several months - or episodically throughout life. Sometimes there may be a clear reason for the development of depression, but reasons may not always be apparent. The costs to the many people who experience depression are high:  personal distress, occupational disadvantage and the impact on relationships. Depression is also linked to  40-60% of suicide attempts, with 10-15% of those diagnosed with major depression successfully ending their lives.(1)

Prevalence
In 1990, the World Health Organization ranked depression fourth out of a total of 15 leading causes of disease burden. By the year 2020 it is estimated that depression will become the second most important cause of disease burden in the world, with women almost twice as likely as men to experience depression in both developed and developing countries alike.(2)
 
Women and depression
So why do more women become depressed than men? There are a number of key areas for us to consider. The first is the influence of women's socio-economic status. Women make up the majority of the workforce in the lowest-paid jobs. Two-thirds of the poorest adults in households are women, and women make up 60% of adults in households dependent on income support.(3-5)
Status relates not only to a woman's economic position but how her gender is perceived within families, communities and society at large. Some studies suggest the lower social status of females and the "traditional" upbringing of girls foster certain traits that may increase the vulnerability of young women to depression. As the female body develops during early adolescence, girls are often compared to standard female stereotypes, which can engender a sense of hopelessness, dissatisfaction, heightened self-awareness and low self-esteem.(6,7)
While some would argue a genetic cause for depression, scientists have not identified a biological mechanism that would explain the role of hormones in depression. Furthermore, the effects of hormone levels on depression have been found to be minimal compared with the influence of social factors.(8)
Social factors that generate early stress, such as childhood abuse and neglect, make it all the more likely for women to develop clinical depression in adult life.(9)
The increase in the number of female victims of sexual abuse during adolescence could also be influential in the later development of common mental health problems.

Substance misuse
Women and Alcohol - A cause for concern describes how young women are using alcohol to cope with stress.(10) The expectation is that alcohol improves confidence and helps you to make friends, and these beliefs continue through the teen years and the early twenties, in tandem with increased consumption.
Heavy drinking is linked with psychiatric morbidity, including clinical depression, with alcohol being implicated in 40% of attempted suicides by women. Often alcohol is used as a way of managing problems such as depression, but alcohol and other substances can intensify and prolong common mental health problems.(11)

Health policy
The present government launched a women's mental health strategy, Mainstreaming: Gender and Women's Mental Health, with the message that the integration of gender and the specific needs of women should take place within the broader context of the Mental Health National Service Framework, the NHS Plan and the Priorities and Planning Framework 2003-2006.(12,13,14,15) For primary care, where the vast majority of mental health problems will present, targets include:

  • Early recognition of mental health problems.
  • Detection and management of conditions that often remain hidden, such as self-harm, alcohol and substance misuse.
  • The facilitation of access to relevant services.

In a review at the University of York NHS Centre for Reviews and Dissemination, important questions were raised about the current level of skill in screening and assessing for mental health problems in primary care.(16) The review highlighted the paramount need for nurses and other health workers to receive appropriate training in core mental health skills. The University of Manchester has developed a training package that contains these key skills.

SCAN
SCAN (Screening, Care, Advice, Next step) is a national programme of mental health training that was developed for NHS Direct by Professor David Richards and Karina Lovell, senior lecturer at the University of Manchester. The aim of SCAN is to equip NHS Direct nurse advisors with skills to detect and respond to mental health problems.

Screening
In order to understand how the individual is experiencing a common mental health problem such as depression and the impact of this on their life, it is crucial to ask questions that provide us with an accurate picture. Screening begins with broad open questions, specific open questions and closed questions that are aimed at clinching detail. This process is described as "funnelling".
It is also vital that a risk assessment is completed at the screening stage. Risk to the individual and others should be carefully monitored, with practitioners aware of appropriate support systems, should the degree of risk warrant further intervention.

Understanding emotion
Central to SCAN is the ABC model of emotion (see Figure 1). In order to understand emotion - be it depression, anger, anxiety, etc - we must first break it down into its three component parts: physical symptoms (autonomic), behaviour and thoughts (cognitions). These elements of emotion are linked and impact on one another.

[[NIP17_fig1_58]]

Care
SCAN provides helpful tools to assess for common mental health problems but places equal emphasis on the approach and attitude practitioners possess in their contact with clients. It is crucial that we see the whole person rather than focusing on a set of symptoms. This means that practitioners must consider the social and psychological aspects of the person's life.

Client centred structured interviewing
The aim of a client-centred structured interview (see Table 1) is to define the problem by gathering pertinent information. The aim is not to diagnose by working through a checklist of symptoms, but to pull together the components that make up the client's personal experience of their difficulties as well as identifying problem triggers and their impact.

[[NIP17_table1_57]]

Problem statement
A problem statement is drawn from the information gathered in the structured interview and provides a focused summary of the problem.
On agreeing a problem statement with the client, the practitioner will then go on to consider which steps need to be taken next. This will be determined by the need of the patient, the nature of their problem and current risk issues, as well as the services available to meet that need. The likely outcome and success of an intervention should also be considered when determining next steps.   

Goals
At the decision-making stage the patient should be asked to consider what they want to change. It is also helpful to discuss how they will know when their goals have been achieved. Goals may need to be graded and broken down into manageable steps. They also need to be realistic and specific. Goals are useful in retaining a focus and in monitoring progress.

Advice and next steps
Having completed the screening process and agreeing a problem statement and goals, the practitioner and client will then go on to consider options for next steps.
There are a number of treatments available for common mental health problems such as depression. Antidepressant medication is helpful for most people with depression, particularly if the depression is considered moderate to severe.(17)
Psychotherapy is another option. Cognitive behaviour therapy (CBT) is a structured treatment supported by evidence from randomised controlled trials.(18) The NSF for Mental Health recognises CBT as a major component in the treatment of common mental health problems, including depression.(13)

Self-help interventions
While CBT is a key treatment within mental health services, many patients will encounter difficulties gaining access to qualified cognitive behaviour therapists. Long waiting lists may be one reason for this, but for those patients with subthreshold depression or anxiety their difficulties may not fall within the referral criteria.
A response to this problem is a "stepped-care" approach that integrates self-help into routine service delivery.(19) Evidence suggests that simple, single-strand cognitive behavioural treatments should be the first choice for clients.(20) Interventions such as behavioural activation, cognitive restructuring and problem-solving can be delivered using a self-help approach and can be effective in the treatment of common mental health problems, including depression.

Conclusion
In developing a strategy for women's mental health, groups of service users were consulted and asked for their expert opinion. A recurrent message was that women's mental health problems be viewed in the context of their lives and the underlying factors that serve to maintain the prevalence of mental distress. What this highlights is a need for an interagency model of service rather than a focus on health/illness in isolation from other factors.
For those of us in practice, this involves understanding how depression shows itself and being skilled in the use of screening and assessment tools that are client-centred, as well as incorporating social and environmental factors. It also means being aware of vulnerable groups and the different ways these people may present to services, creating links with housing, welfare rights, social care, criminal justice and education agencies, and considering the effects of gender on people's presentation and pathways into services.

References

  1. NICE. Guidance on the use of ­computerised CBT for anxiety and depression. Technology appraisal ­guidance No 51. 2002.
  2. Women's mental health: an evidence based review. Geneva: WHO; 2000.
  3. Oppenheim C, Harker L. Poverty: the facts. London: Child Poverty Action Group; 1996.
  4. Department of Social Security. London: TSO; 1997.
  5. Lister R. Women's economic dependency and social security. Manchester: EOC; 1992.
  6. Wichstrom L.   Dev Psych 1999;35:232-45.
  7. Obeidallah DF et al. J Youth Adolescence 1996;25:775-85.
  8. Brooks-Gunn J, Warren MP.Child Dev1989;60:40-55.
  9. Bifulco A, Moran P. Wednesday's child: research into women's experience of  neglect and abuse in childhood and adult depression.  London: Routledge; 1998.
  10. Thom B. Women and ­alcohol - a cause for concern. London: Alcohol Concern; 2000
  11. HEA. Health update - alcohol. London: HEA; 1997.
  12. Department of Health. Mainstreaming: gender and women's mental health. London: DH; 2003.
  13. Department of Health. NSF for mental health. London: TSO; 1999.
  14. Department of Health. The NHS plan. London: TSO; 2000.
  15. Department of Health. Improvement, expansion and reform, the next 3 years: priorities and planning framework 2003-06. London: DH; 2003.
  16. NHS Centre for Reviews and Dissemination. Improving the recognition and management of depression in primary care. University of York: 2002.
  17. WHO. Guide to mental health in primary care. London: Royal Society of Medicine Press; 2000.
  18. Roth A, Fonagy P. What works for whom? A critical review of psychotherapy research. New York: Guilford Press; 1996.
  19. Davison G.J Consult Clin Psychol 2000;68:580-5.
  20. Lovell K, Richards D.  Behav Cogn Psychother 2000;28:370-91.