The word ‘depression’ is bandied around. People say it when a netflix series is over a bit too quickly or the supermarket has run out of a flavour of crisp. There is still so much misunderstanding about it. Depression can debilitate, cause undue stress, make everything grey, can stop a father seeing his worth and can remove the most human pleasures from our life. Ultimately, at its worst, depression will make someone feel so worthless they will take their life, even when surrounded by loved ones. This blog isn’t here to talk about what depression is and it’s not full of motivational quotes or 3 magical tips to cure depression.
One problem I want to outline in this blog is that often people have no idea what to do, say or expect when it comes to something as widespread, common yet often misunderstood as depression. So, let’s break down some stigma and build a picture of what happens and what to expect. Please note this is not how it happens for everyone, everyone’s journey will vary and where you live will vary. I apologise in advance, this is my opinion, despite how balanced I’ve tried to be and it’s a bit Wales and NHS centric. I hope you’ll get the gist of it. So let’s get into it.
Let’s do a bit of a thought experiment. Scenario A; imagine you are out and about, you trip and break your leg. A fairly untypical occurrence. What would be your journey from break to recovery? I bet with a high degree of accuracy you’d probably be able to list what would happen; name most of the professionals that would be involved, you may even know the time frames and procedures involved. It might be something like; call an ambulance or get a lift to A&E, get triaged by a nurse, wait a bit in a waiting room, get some pain meds, get an x-ray, you’d prob see a Dr, maybe an orthopaedic consultant, depending on break, you might need it set (you know this hurts and you’ll be sucking on gas), it may be splinted for a bit, then maybe a plaster cast, maybe an operation, maybe a short stay in hospital, no weight bearing for 4 weeks ish, see a physio, cast on for 6-8 weeks, rehab, time off work, expect some muscle waste. You get the picture.
Now, let’s do the same with depression. Scenario B: Imagine you are feeling profoundly sad and at times completely numb for around 2 weeks straight despite best efforts you haven’t left the house. You question your existence; ‘what’s the point…I don’t want to be here…I’m completely worthless’. When someone you love offers help, you get very irritable and now you just avoid them. You haven’t showered for a couple of days and you’re still off work. You can’t even envisage getting out of this rut. Thinking back over the last few months you realise that you haven’t felt great for a while. You start thinking; ‘am I depressed?’ What would be your journey from this episode to recovery? Are you as confident as you were with Scenario A? What would happen? What do you do? Where do you go? Who would you see? Not as easy as a broken leg is. Chances are you’re thinking about seeing a GP, maybe getting meds? But what do these meds even do? Who is next? Do you see a psychologist? A psychiatrist? Then what? Is there a quick fix? As a society, we need to know a bit more about what goes on and to demystify the journey. So lets demystify what happens.
Should I see someone? Yes. Typically the first point of call in getting help is going to the GP, you may need to ask someone to help with this if you’d struggle to make an appointment. Your GP surgery is a bit like a gateway and overseer of your care, bit like step one in accessing healthcare. Lots and lots of people with a range of mental health problems will see someone in their surgery. It’s common and nothing strange or weird about it. There are a range of professionals or workers whom you might see, possibly a dr, a wellbeing practitioner or a mental health professional. You’ll be asked what problems and symptoms you are experiencing, for how long and likely how your life is being impacted. They may also want to know what stressful things are going on for you right now. They may also check in with your sleep and if you’re eating ok. They may make some suggestions, or ask to see you again in a few weeks. This is because sometimes if you have gone through a difficult time, like a separation or a bereavement, feeling down is normal, and naturally things may not be perfect but may improve with a bit of time.
If your difficulties are mild, they will likely direct you to a local organisation or a local project or service, such as a local Mind charity. Or they may want you seen for further assessment from a NHS provider and or may offer some medication down the line. If difficulties are severe and you need more urgent help, your GP may refer you to a specialist service such as a community mental health team. More on these options below.
Will they ask if I’m thinking of killing myself? What if I say yes? Whoever you see, they probably will. It’s a very common question. Saying yes doesn’t mean you get locked up or pumped full of meds. It doesn’t mean a referral to social services or a call to the police, unless risks to yourself or others are severe. You may be surprised to hear that saying you have thoughts about dying, escaping or turning the lights off is pretty normal and for many just part of the experience of depression. For the most appropriate step for your needs you need to be honest. Answering this difficult question is a lot easier than not. Trust me. Most MH professionals are pretty good at working out the next steps. Depending on your risk and the bigger picture, they might just give some advice, they’ll likely want to know what support you’ve already got, they may provide a helpline, they may make a routine referral to another team or serivce or they may help you access urgent services like getting to the hospital. Read my blog about ‘the difficult question’ here.
What do I say to the doctor or professional? I always go blank. You just sit down and say ‘I think I’m depressed’ or ‘I’ve noticed my mood has been low for sometime’. A good tip is to write down what the problems are, what symptoms you are having and what it’s stopping you from doing. This could be a list of things like; mood is low a lot of the time, I’m tired all the time, irritable and snappy, sleeping too much, dwelling on the past, stopped going to the gym and struggling at work. Lastly, on the bottom of that note write the questions ‘what are the options and what choices are available?’ This is important, you want to leave that room or finish the call with options to consider. You may not need to ask this, as the person you are seeing may give them to you. Keep these notes simple. Don’t overthink it too much. An essay is too long for a doctor to read and makes your problem look bigger, more complex and more uncertain. It’s then the professionals job to ask more questions and help you understand your choices.
I’ve been sent to a local mental health charity – If you are lucky enough to live in a town that has some organisations and charities such as MIND, you may be referred there by GP or MH professional or advised to visit or call them. Places like Mind do a wide range of things for a range of people with a wide range of problems. You’ll likely turn up and see people there with a range of problems from one end of the spectrum to the other. You’ll see one of their workers who’ll ask some questions and may be able to make suggestions around accessing interventions such as local counselling resources, self help groups, courses, self help interventions, and often they will be able to provide a wide range of knowledge about things going on in the area. There is often a lot of social stuff that is going on that has the benefit of having nothing to do with talking about things, nothing to do with being ill, medication or therapy. Suggestions could be a social group, a walking club, allotment group, volunteering or a support group that you could attend. Some suggestions may not be for you, and that’s ok. Don’t be surprised if what is suggested is nothing medical or is not a talking therapy. When I speak with people who make big changes to the way they feel, a lot of the time it’s not the psychological or medical interventions. It’s getting out, doing things that are fun, playing sports, being hands on, being around others, being in nature or being active. These social activities can be as powerful as anything else, often more so.
Will I be pumped full of medication? – I am in no position to provide advice or recommendations with medication, but I usually will talk with clients a little about them, just to make sure they understand what they are and what they do. If you see a GP after subsequent occasions regarding depression and/or you have already done therapy or intervention or something in the community, depression is clearly having a big impact on you. Your GP might offer some choices that are personal to you and one of those choices may be medication. Your GP will take into account lots of different things. For example they may be cautious about medication if there is a reason they may not work well or risks outweigh potential benefits. An example could be if you had some underlying physical health problems that meant it would be unsafe to take anti-depressants. The medication that typically would be offered would be something like Sertraline or Citalopram. These are types of SSRI’ or Selective Serotonin Uptake Inhibitors. Serotonin is a neurotransmitter that’s pretty well understood and there is evidence that they can help (find out SSRI’s here). I would say that it’s a given nowadays that professionals will never say ‘depression is a chemical imbalance and antidepressants will fix the chemical imbalance’. Depression is far more complex and personal. People’s depression is often caused by stuff that happens in life and the way we deal and think about this stuff. Sometimes medication can just add that small layer to help aid your recovery. From my personal and professional experience, I have spoken to people where SSRI’s have helped massively, for others they don’t. For some antidepressants can make a 1% difference, but that one percent could be the difference between taking their life and not. For some they cause side effects. Good rule of thumb; change what you’re doing in order to feel better, if this doesn’t work or you cannot make changes, medication might be an option that is worth having a discussion with your GP about.
I need a further assessment from another service. There is a chance your GP will refer you to another team in the NHS that would be a non urgent service. Often referred to as a Primary Care Service. This team will be a team that will offer some psychological interventions and you’ll probably need to wait a little while, perhaps a few days to a few weeks to hear from them. With most services, you’ll get a letter that you’ll need to respond to that invites you to an initial assessment, face to face or over the phone. Read it as usually there is a period you need to contact them otherwise they’ll assume you don’t want the assessment and you will have to go GP again. Ask your GP for more information about this service, perhaps there is a website or a leaflet to look through.
So you’ve got an assessment booked. This assessment will be speaking with someone to work out if it’s the right service for you and to discuss what’s wrong. Chances are, this will be with a mental health professional, this could be with a mental health nurse, an occupational therapist, a practitioner or another professional of some description. Whoever you speak to, they’ll know alot about mental health and will have a longer conversation with you from anything from 15 mins to an hour, maybe a follow up appointment. I 99% guarantee that anything you say won’t surprise them in the slightest and they’ll have in front of them the referral letter or notes from whoever referred you. They’ll want to know similar stuff to whoever saw you in your surgery, but in more detail. They will probably want to know how you cope when low, what kind of thoughts you have when low, if you are using alcohol or drugs, what a typical routine looks like, what past bouts if any looked like and what has led to this bout and what your strengths, protective factors and support networks are. Also if you have had therapy in the past they’ll probably want to know what was good/bad about it. It might feel like a bit of interrogation at times, but this assessment is aimed at finding out the most appropriate next step that is unique to you. Just like going to your GP, I’d really recommend writing things down prior if you’d struggle in remembering things.
The suggestions will vary depending on your needs and there is usually more than one approach. Choices may include; self help, online courses, group work, 1:1 work, counselling, psychological talking therapy of which there is a range of options and going to a local charity or organisation. Some suggestions may be specific to depression like a Cognitive Behavioural Therapy Course specifically for depression. Sometimes non depression specific options might be offered such as learning about stress, bereavement or general counselling for example. It just truly depends on you and what the best fit might be. They may even suggest nothing or provide some practical suggestions like returning to the service in the future if there is a deterioration. Maybe you are interested in a particular approach. Don’t be afraid to ask more about it, the assessor will tell you more about it and if interventions are available or the best fit for you. Yes there will be a wait list, usually group interventions will be a bit shorter and 1:1’s will be a bit longer. Just ask about a rough period of time you’ll be waiting.
I am all for choice, however don’t turn up to the assessment expecting to have 1 particular approach as some approaches have a pretty niche criteria, simply might not be available or might not have an evidence base to help you with your particular problem. Sure, have some ideas, but keep your mind open. If you don’t like the suggestions, say why and ask about other options. If offered a psychological intervention remember there is no magic wand to fix your difficulties. You’re not going to lay down on a chaise longue. There is no such thing as a therapy where you are talked to and feel better. Interventions require talking, learning and trying new things out particularly in between a session. You are going to speak with a human who is trained and has experience with mental health and who’ll make it clear what and why they do what they do. A good metaphor for an intervention is a bit like seeing a personal trainer. In order to see results you actually have to exercise and adhere to a training plan even when you’re not with them until you achieve your goals. If it’s in the NHS, chances are your therapist or counsellor will keep your GP in the loop when treatment is over.
The doctor has sent me to the community mental health team. This decision is usually made when what is on offer in your local community does not meet your needs and the severity of your symptoms or possible risks need further assessment. Often referred to as a secondary service. A Community Mental Health Team or CMHT has a range of professionals; mental health nurses, social workers, psychologists, psychiatrists, occupational therapists and there will also be support workers. CMHT’s will often work with people who need a bit more intensive support and/or a review from a psychiatrist. A psychiatrist is basically a Dr. who specialises in mental health and has a bit more scope and knowledge of mental health and can also discuss with you and prescribe medication for mental health that your GP might not. The CMHT will initially assess you, how quickly will depend on the severity. It could be within a month or even that day. They also act like a gateway into further specialist help and support which includes teams that provide specialist interventions, psychology and teams that can support you in a crisis. At this stage, hospitals may be considered. When under the care of a CMHT, you may be allocated a professional like a nurse to help oversee your care and be a point of contact. You’ll have appointments with this person at your home, at the CMHT or perhaps in the community. They will chat to you, support you with your needs, help you to understand your difficulties and help get you specific support. They’ll also be there to help manage the next steps if you are really struggling. You don’t stay with them forever, the aim of their support is to help you recover to the point that you no longer need that level of care. At this stage they will support you in accessing other services or interventions when this time comes.
Are they going to lock me up? You are not going to be ‘locked up’. It’s been a few years since I worked on a ward, but from my experience it’s only the very extreme end of the spectrum of people with depression getting admitted to hospital, and typically this will be on a voluntary basis. There are occasions where people are admitted against their will. This is a decision that is made by a number of professionals and even family members and is never ever taken lightly and is bound tightly by legislation. With regards to depression, admission is usually reserved for times where a person is depressed to the extent where there are imminent risks to their own safety and they lack the insight to even understand these risks. Hospital will provide a safe and secure environment where medication can be provided regularly. There will be regular appointments with a psychiatrist, medics and nurses, perhaps some physio, occupational therapy and psychology. Also outside services may involve professionals at your CMHT, so things are in place when you leave.
There you have it. I hope that if you are someone who’s depressed, accessing help is now a bit demystified.
About the author
I have been working as a mental health nurse since 2016 and have been around the block working in a lot of different areas. At present I work in a service where I assess people and provide interventions. I love my job, I love learning and talking to people about mental health and wellbeing. This article represents my personal opinion and is certainly not medical advice. If you have concerns about your mental health please speak with a GP or health professional.
The CALL helpline – 0800 132 737 or text HELP to 81066. CALL Offers emotional support, a confidential listening service and information/literature on Mental Health and related matters to the people of Wales and their relatives/friends