Specialty Areas

Depression & Bipolar

Everyone experiences emotional highs and low. It is normal to experience periods of sadness and low mood in response to stress and the daily hassles of life. Depressed mood becomes more serious when it remains for a longer period of time and starts to affect your ability to cope and your quality of life. Clinical depression defines a distinct change in mood state and functioning that continues longer than just a few days. A person will experience a number of symptoms and signs which cluster together and if left untreated can result in impairment in many facets of life, including work performance, relationships and general health. Key symptoms include: sleep disturbances, appetite changes, low mood, loss of pleasure in usual activities, low energy, impairments in concentration and decision making, feelings of worthlessness and inadequacy and more seriously, suicidal thoughts and plans. There are many factors that can be involved in the cause of depression. These include psycho-social factors such as relationship breakdowns, unresolved issues from the past, personality styles, coping behaviours and the way you deal with stress, how you interpret life and the world in general and untreated anxiety disorders just to name a few. Often there is a good indication for using anti-depressant treatments (i.e, medications such as SSRI’s), but counselling is also necessary to make sustained change and reduce your likelihood of having further episodes in the future. Like any mental health problem, there is absolutely no shame in having depression. Don’t let feelings of shame, isolation or “weakness” prevent you from seeking help. We understand that can be hard, but getting treatment earlier can make all the difference.

Bipolar Disorder & mood swings

Within the broad diagnostic umbrella called Bipolar Disorder there is in fact a lot of variation. The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) provides the basis of various formal diagnoses that you can receive. These diagnoses attempt to capture the differences that individuals can experience in terms of the type of symptoms, the intensity or duration of symptoms, and the timing of symptoms in relation to each other. It can also be helpful to see these symptoms dimensionally with increasing distress and impairment as one moves from cyclothymia to bipolar I disorder. One commonality across all subtypes is the cyclical nature of symptoms. Bipolar Disorder is characterised by experiencing episodes of hypomania or mania and episodes of depression. While hypomanic or manic people describe feeling high or euphoric or even irritable, having extreme self-confidence, sleep disturbances, being talkative and a sense that you can’t get your words out fast enough, having great ideas and feeling more inspired, racing thoughts and getting very busy. If you are experiencing a (hypo)manic episode, you may also engage in activities that are harmful for yourself and your family. Examples of such behaviour may include excessive and impulsive spending, reckless driving and risky sexual behaviour.

It is also possible to experience mixed episodes. A mixed episode is a manic or hypomanic state where you also experience depressive symptoms. In essence this is likely to be intense fluctuations of mood that can vary from one moment to the next.

You do not have to have all of the above symptoms to have Bipolar Disorder (there are various decision rules that clinicians use). Additionally, even if you do not tick all the boxes for a formal diagnosis, if your symptoms are interfering with your life you can benefit from psychological treatment. The reality is that symptoms do not necessarily fit the diagnostic box and less severe symptoms of (hypo)mania and depression can also be very distressing. The experience of bipolar disorder is unique for each sufferer and the frequency, nature and duration of episodes vary markedly. For example, some people report very few hypomanic or manic episodes but many depressive episodes. The reverse can also be true. Some individuals experience repeated episodes cycling rapidly from one mood state to the next while others experience periods of relative wellness in between episodes.

The difference between Bipolar I Disorder and Bipolar II Disorder is the experience of mania and hypomania. If you meet criteria for Bipolar I Disorder you have experienced at least one manic episode in your lifetime. For Bipolar II Disorder you have experienced at least one hypomanic episode in your lifetime. The difference between mania and hypomania is the intensity of the symptoms. If you experience a hospitalisation, a mixed episode, experienced delusions or hallucinations, or engaged in behaviours that have harmful consequences for yourself or your family you have experienced a manic episode. Hypomania is a less severe form of mania. You are likely to still be able to work and function OK. You may even enjoy these periods as you may feel productive and experience great creativity. It is easy to overlook hypomanic episodes as many patients with Bipolar II Disorder only present for help when they are depressed. However, from a psychological perspective, it is important that both hypomania and depression are addressed. This is because the same psychological vulnerabilities that make you susceptible to hypomania or mania also render you vulnerable to depression. Additionally, there is some evidence to suggest that those with Bipolar II Disorder have a shorter time to relapse compared to people who experience depressive episodes only and the degree of depression they experience is more severe.

Many people with bipolar disorder also describe symptoms of anxiety. In fact, studies have shown that up to 80% of those with bipolar disorder also suffer from an anxiety disorder. Anxiety disorders predict a worse course for those with bipolar disorder with those with both conditions experience more episodes, more hospitalisations, and more time symptomatic than those without anxiety disorders. Particular anxiety disorders such as social phobia and generalised anxiety may have a special relationship with bipolar disorder and predicts a worse outcome. Unfortunately, in clinical practice anxiety disorders are under-recognised and rarely diagnosed but they can have a real impact on the severity and frequency of your symptoms. Therefore, psychological treatment must also target these symptoms to reduce risk of relapse. Psychological therapy is the treatment of choice for anxiety disorders and symptoms and you can get real relief from getting treatment.

Post Natal Depression

Postnatal depression is very different from the “baby blues” which up to 70% of women experience after birth. Postnatal depression is a serious disorder that requires prompt and targeted treatment. It typically occurs within the first four weeks after childbirth and sufferers can experience the following symptoms:

• Low mood
• Feelings of being overwhelmed and extremely anxious
• Panic attacks
• Irritability
• Difficulty concentrating or remembering things
• Sleep difficulties (not just due to a disrupted sleep cycle due to night feeds etc)
• Appetite disturbance
• Feelings of hopelessness and being unable to cope
• Loss of confidence and low self-esteem (particularly in perceived ability to be a good mother)
• Extreme indecisiveness, this may also manifest as excessive reassurance seeking from other regarding decisions about caring for baby
• In more serious cases, suicidality or even attempts
• Excessive guilt caused by having negative feelings towards the new baby. Typical emotions that women describe as distressing are anger, resentment or hostility.
• Problems with mother/baby attachment

Causal pathways or “risk factors” for Postnatal Depression

As with all mental disorders, the causes of postnatal depression are multi-faceted. It is useful to differentiate those risk factors that pre-exist before the arrival of your baby and those that arise after your baby is born. Those that can be present before the birth of your baby include:

• A genetic vulnerability to mood disorders such as depression or bipolar disorder
• A previous history of a mood disorder
• Previous history of an anxiety disorder
• Pre-existing psychological vulnerabilities such as perfectionism or dependence
• Dysfunctional relationships
• Concurrent social stressors such as relationship breakdowns, social isolation or financial difficulties
• Physiological stressors such as hormonal changes, fatigue, physical complications
• A previous history of pregnancy or birth-related difficulties such as miscarriages, terminations, stillbirths, premature birth or the death of a previous child
• If the current pregnancy is unwanted
• Poor social supports
• Protracted fertility difficulties/treatments

Those that can arise in the postnatal period commonly include:

• A traumatic birth experience (e.g., high intervention births, post-birth surgery)
• Prolonged feeding difficulties and disappointments
• If the baby is ill or there are physical complications
• If the birth process did not fit with previous expectations

If you recognise any of the antenatal risk factors shown above, you can reduce your risk by intervening early. In particular you can address the psychological risk factors and also plan adaptive coping strategies to put in place after your baby has arrived. Seeking help before your baby is due can reduce the risk of developing postnatal depression as studies have shown that mood and anxiety symptoms during pregnancy increase the risk of developing post-natal depression.

It is also important to remember that a pregnancy can trigger a lot of worries and anxieties. Sleep deprivation alone, is enough to cause significant mood disturbance in many mothers. You are more vulnerable emotionally due to hormonal fluctuations and it is possible for pre-existing worries and anxieties to flare up during this time. For example, you may find yourself worrying about all the uncertainty around the birth and your transition into motherhood. You may also be concerned about how the way you parent is going to be influence by how you yourself were parented. A frequent concern is “I don’t want to make the same mistakes my parents did”. This can also fuel a lot of anxiety and worry. There is also increasing pressure for women to find motherhood and pregnancy an amazing, overwhelmingly positive experience. There are certainly many positive exciting aspects to it but also difficult ones as well. You may find yourself judging yourself harshly e.g., “I don’t know what is wrong with me, everyone thinks I should be so excited”. By addressing any anxieties and worries before or during a pregnancy you can greatly increase your psychological resilience in preparation for the challenges of parenthood.