DEPRESSION DISORDERS

Dr. Naresh Vadlamani, Chief Consultant Psychiatrist

Depression and Depressed are misnomers of Medical Depressive Illness.
A person is diagnozed to be suffering from depressive disease if:

• Has dull and low mood and feels stressed for weeks/months
• Feels very tired, weak and suffers from headaches, backaches, body aches for weeks/months without relief
• Feels less interested in job, daily works, studies and finds it difficult to wake up in the morning as he is not interested to do anything
• Has decreased concentration leading to poor performance in studies, jobs etc
• Feels very lazy and becomes slow and postpones work
• Becomes indecisive, loses confidence and feels inferior
• Has negative thoughts including hopelessness, worthlessness and pessimistic thoughts
• Has sleep problems for days/weeks

All the above complaints start gradually over a period of days, weeks and months, one by one and when they become overwhelming, people will start to have suicidal thoughts.

Throughout the course of our lives, we all experience episodes of unhappiness, sadness, or grief precipitated by unexpected events like failure in exams, rejection by loved one, death of a close one, personal tragedy or difficulty such as divorce, loss of a job, etc and may feel depressed (some people call this "the blues"). Most of us are able to cope with these and other types of stressful events. Over a period of days or weeks, majority of us are able to return to our normal activities. This is called Normal Reactive Depression.

Normal Reactive Depression is different from Medical Depressive Illness or Disease.

Normal Reactive Depression requires no treatment. Just assurances, supportive empathy and encouragement would be useful. It does not affect day to day activities and routine life.

Medical Depressive Illness or Disease is not a normal variation of mood. The symptoms of this disease last for weeks and months and the person suffers a lot affecting their regular pattern of living.It is the illness in the brian's nerve circuits that affects or changes our thoughts, moods, behavior, activity, attitude, habits and personality from what we normally are. Some neurochemicals like Serotonin, Norepinephrine and Dopamine are less in quantity in some parts of the brain leading to dysfunction of the brain's neural circuits. 

Medical Depressive Disease requires treatment with medicines and counseling from a trained mental health professional.

How many in this world are suffering from Depressive Disease?

According to World Health Organization (WHO),

• Depressive disease is the third commonest illness in the world.
• It affects about 340 million people all around the world annually.
• 15%-20% of the world's population i.e 700million to 1 billion people suffer from this Disease some point of time throughout their life time.
• It is estimated to contribute to 50%-70% of all suicides. About 5%-10% of women and 2%-5% of men will experience at least one major depressive episode during their adult life.
• Depressive Disorder is the world’s no.1 disease causing maximum disability in lost years and the numbers are increasing.
• Depressive Disease affects people of all races, incomes, and ages.

How is Depressive Disease treated?

Medicines with added counseling or psychotherapy are the best methods of treatment. This treatment is provided by your Family/General Physician trained in psychiatry or by the Psychiatrist. The good news is that Depressive Disease can be diagnosed and treated effectively in most people. It is 100% curable and treatable.
The biggest barriers to overcome are:

• STIGMA - Many people hesistate to accept that they are suffering from Depressive Disease and more so are reluctant to see a psychiatrist. This is the main stumbling block that prevents people from getting the effective and curable treatment.
• Recognizing and Diagnosing that one has Depressive Disease (and not depression/being depressed) and seek the appropriate treatment.

How does one recognize and diagnose Depressive Disease?

What are the symptoms?
Depressive Disease is not something one feels for a day or two before feeling better. In true Depressive Disease, one suffers for weeks or months if one doesn't seek treatment. If one has depressive disease, they are often unable to perform daily activities as before. They may not care enough to get out of bed or get dressed, much less work, do errands, or socialize. During this phase, the depressive illness fluctuates with few normal days of functioning and mood. One may feel better on few days of the week but then the depressive symptoms prevail on most days and gradually the number of days of depressive illness increases.
When one meets their doctor, they usually complain of:

• HEADACHE, BACK PAIN, BODY PAINS AND PAINS IN OTHER PARTS OF THE BODY ESPECIALLY HANDS AND LEGS.
• WEAKNESS DESPITE EATING WELL ESPECIALLY IN THE HANDS AND LEGS.
• TIREDNESS DESPITE DOING REGULAR WORK.
• SLEEP DISTURBANCES - DIFFICULTY IN FALLING ASLEEP OR DISSATISFACTION IN SLEEP.
• DECREASED APPETITE.
• GASTRIC PROBLEMS LIKE ACIDITY, CONSTIPATION AND BOWEL PROBLEMS.

But the diagnosis or the illness is not the pains, weakness or sleep disturbances but symptoms of underlying depressive illness. The treatment is not pain killers, antacids, multivitamins or sleeping tablets. Many fail to recognize this and continue suffering with the illness.

ADULTS

One may be said to have depressive disease if one has at least 4 or more of the following :
Over the past two weeks (usually over the past one month or more, on most of the days over past several months):

• Feeling sad or depressed.
• Loss of interest in job - leading to decreased efficiency,changing jobs and in some job loss; loss of interest in housework - leading to unclean, unkempt house, delays in washing clothes and dishes and cooking food; loss of interest in day to day activities like brushing teeth, bathing, wearing non-ironed clothes and lacking interest in appearance.
• Feeling tired most of the time despite doing regular or less than regular work leading to postponement of regular work, delayed bill payments and procrastination.
• Lack of enjoyment or pleasure in activities than before leading to dropping of hobbies, avoiding socialization, going out or watching movies.
• Feeling lazy, lethargic and being slow leading to postponement of work.
• Decreased concentration leading to memory problems and forgetfulness leading to poor academic performance or accidents.
• Decreased confidence, self esteem, self worthiness or feeling inferior to others.
• Become indecisive, fickle-minded, dependant, unable to organize, plan etc.
• Thoughts that other people are bad, thinking bad about themselves or ignoring them and will not help them.
• Thoughts of worthlessness, being a burden to family members, unworthy of love of near and dear ones.
• Thoughts that the world is a bad place, full of negativity etc.
• Thoughts of guilt, self hate and frustration.
• Thoughts that current situation will not improve in future, hopelessness, helplessness and thoughts of being alone in the whole world.
• Decreased initiation, motivation or enthusiasm than before.
• More irritability, anger, explosive behavior than before.
• Sleep disturbances like difficulty in falling asleep leading to internet surfing or watching TV ( channel surfing), waking up early or late, wanting to sleep more and feeling dissatisfied with the sleep.
• Appetite disturbances( change in eating habits) - not interested in eating or eating more than usual or even late night snacking
• All these thoughts lead to sleep medication abuse, alcohol misuse, headaches/backaches (unexplained/no clear medical cause) and pain killer abuse, antacid abuse etc.
• Ideas, thoughts, plans of wishing to die, suicide harming oneself, suicidal attempts in severe paitents.

When still undiagnosed or untreated, it progresses to severe stage in some patients leading to:

• Non-compliance with current medication/diet/exercise ( depressive disease decreases the motivation) for other medical illnesses leading to complications and or death due to medical illness (commonest cause of death in depressive patients).
• Addictive behaviors like Cigarette smoking, alcohol abuse, sleeping tablets abuse and other substances.
• Self harm or suicide attempt or completed suicide.
• Homicide of family members and then suicide.

CHILDREN

Children with depressive disease also experience these classic symptoms, but may exhibit other symptoms as well, including the following:

• Poor school performance
• Persistent boredom
• Frequent complaints of physical problems such as headaches and stomach-aches
• Some of the classic "adult" symptoms of depressive disease may also be present in children, such as change in eating or sleeping patterns. (Has the child lost or gained weight in recent weeks or months? Does he or she seem more tired than usual?)

Parents of children with depressive disease report noticing the following behavior changes. If you notice any of the following, discuss this with your doctor.

• The child cries more often or more easily.
• The child spends more time alone, away from friends and family.
• The child actually becomes more "clingy" and may become more dependent on certain relationships. This is less common than withdrawal, though.
• The child expresses thoughts about hurting him or herself, or exhibits harmful behavior. The child seems to be overly pessimistic or exhibits excessive guilt or worthlessness.

ELDERLY

While any of the classic symptoms of depressive disease may occur in elderly people, other symptoms also may be noted.

• Diminished ability to think or concentrate
• Unexplained physical complaints (for example, stomach pain, changes in bowel habits, or muscle aches)
• Memory impairment

Causes of Depressive Disease

• Why does one have Medical Depressive Illness or Disease?
• What causes Medical Depressive Disease?
• Why does the Brain have less chemicals?

In fact, there is no single cause.

Exam Failure, love rejection, adverse events DONOT cause depressive disease. They act as possible precipitants and may contribute to development or worsening of already existing depressive disease.
Neuroscientists report that Depressive Disease develops due to a combination of several contributing factors. They include genetic, several predisposing factors and persistent stress. In people who are prone to develop Depressive Disease, stressful events act like triggers or precipitants and added to these stressors, our body's vulnerability and coping mechanisms give way.
All these factors over a period of time lead to changes in the brain's nerves and decrease neurochemicals which in turn are responsible for changes in the thoughts, mood and actions. The neurochemical changes occur over a period of several days, weeks, months or even years leading to symptoms of depressive illness.
The levels of the neurotransmitters can be affected by a number of factors like:

• Heredity - Research is ongoing as to exactly which genes are involved in depressive disease/disorder. Just because someone in the family has depressive disease, it doesn't mean you too will have depressive disease. Likewise, you can have the depressive disease/disorder even if no one else in your family is known to have depressive disease.
• Personality - People with certain personality traits are more likely to suffer from this depressive disease/disorder. These include negative thinking, pessimism, excess worry, low self-esteem, over dependence on others, and ineffective responses to stress.
• Medical illnesses- depressive disease is more likely to occur with certain medical illnesses. These co-occurring illnesses include heart disease, stroke, diabetes, cancer, hormonal disorders (hypothyroidism), Parkinson disease, and Alzheimer disease. Depressive disease should NOT be considered a "normal" or "natural" reaction to such illness.
• Medications - Some medications used for long period, such as certain blood pressure medicines, steroids, sleeping pills, and even birth control pills in some cases, can cause depressive disease/disorder.
• Substance abuse - While it has long been believed that depressive disease caused people to misuse alcohol and drugs in an attempt to make themselves feel better ("self-medication"), it is now thought that the reverse is often the case; substance abuse can actually cause depressive disease/disorder.
• Situations - Difficult life events, loss, change, or persistent stress can cause neurotransmitters to become unbalanced, leading to depressive disease. Even happy events, such as childbirth, marriage, can be stressful and cause postpartum depression.
• Diet - Deficiencies in certain vitamins, such as Folic acid and B-12, may cause depressive disease.

The causes of Depressive Disease is complex. The equation that best describes the factors leading to this complex disease is:

• Genetic Vulnerability (i.e having more genes that lead to depressive illness).
• Past history of persistent stressors and ongoing stressors like in stressful job, difficult financial situation, difficult marriage/relationship, current severe medical illness
• Triggering or precipitating event like, marriage, breakup, divorce, loss of job, failure in an exam, deadlines for debt payments, crop failure.

Treatment of Depressive Disease
Treatment includes medicines and counseling or psychotherapy including other treatments like Cognitive behavior therapy, supportive therapy, changes in lifestyle and behavior, psychotherapy and complementary therapies. Without treatment, the disease patient suffers for more than 6-12 months or much longer and may never get better in some patients. With treatment, the suffering is lessened, duration of suffering is lessened and the patients can lead a normal regular life after recovery.

MEDICATIONS

• Antidepressants are generally prescribed.
• Treatment is provided by psychiatrists who are medical doctors who have completed specialized training in depressive disorders and treatments.
• Antidepressant medications are not sleeping pills or addictive in nature.
• They have to be taken initially at a small dose with gradual increases in doses under supervision of a psychiatrist for about 6 - 9 months on the dose to which they respond.
• In those who have been suffering from the depressive disease for a long time or repeatedly, the medication have to taken for at least 2 years or longer as advised by the psychiatrist.
• People with depressive disease can safely be treated in a series of outpatient visits.
• Hospital care may be necessary for people with more serious symptoms and is required for those who are contemplating suicide or cannot care for themselves.

Types of Medications
The major classes of antidepressant medication are the selective serotonin re-uptake inhibitors (SSRIs), the Tricyclic antidepressants (TCAs), and the atypical antidepressants.
SSRI medications increase the levels of serotonin in the brain. For many people, these medications are the first choice. Examples of these medications include: Sertraline, Escitalopram, Fluoxetine, Citalopram, Paroxetine, Fluvoxamine, etc.
Sertraline and Escitalopram are the the most widely prescribed and the best antidepressants to be prescribed as the first line medication.
TCAs are often prescribed in severe cases of depressive disease/disorder or when SSRI medications don't work. Examples include: Amitriptyline, Clomipramine, Imipramine, Nortriptyline, Dotheipin etc.
The atypical antidepressant medications work differently than the commonly used SSRIs. These medications may be prescribed when SSRIs have not worked or in select people. They include: Bupropion, Mirtazepine, Venlafaxnie, Desvenlafaxine, Tianeptine, etc.

Follow-up

• Usually the psychiatrist/doctor will review more frequently, perhaps as often as every week or every other week, for the first 6-8 weeks after the initial diagnosis of depressive disease.
• Inform the doctor/specialist psychiatrist about any medication side effects or urges to hurt self or others.
• Nearly all those who take antidepressant medications get better.
• It may take 1-2 weeks to start feeling better.
• Some people may not start feeling better for about 6 weeks.
• One should not give up taking the medication if they don't feel better right away.
• Doctor/Psychiatrist will review during this period to see if the symptoms are better. If they are not, he or she may increase the dose or prescribe a different medication.
• Even after they get better, one should continue to take the medication for 6-9 months.
• Stopping the medication too soon may cause the symptoms to return, or to get worse.
• Some people need to take the medication for longer periods of time to keep the depression from returning.
• Do not stop taking the medication without talking to the doctor/psychiatrist.
• If it is agreed that it is time to stop the medication, the dose usually will be slowly tapered to prevent these effects.
• The side effects of antidepressant medications vary considerably from drug to drug and from person to person and include dry mouth, nausea, tremor, acidity insomnia, constipation, etc.

Psychotherapy or Counseling Sessions

• Psychotherapy or counseling ("talk therapy") involves working with a trained therapist to figure out ways to solve problems and cope with depressive disease.
• In general, these therapies take weeks to months to complete. Each has a goal of alleviating your symptoms.
• More intense psychotherapy may be needed for very severe depressive disease or for depression with other psychiatric symptoms.
• Each Counseling or psychotherapy session is done once or twice a week and lasts for about one hour and is mostly done on the same day and same time of the week.
• Each session costs about $100 - $ 250 and equivalent in other currencies depending upon the training, experience and qualifications of the psychiatrist or psychotherapist.

Three major psychotherapies or types of counseling are commonly used to treat depressive disease/disorder.
InterPersonal Therapy (IPT): This helps to alleviate depressive symptoms and help one develop more effective skills for coping with social and interpersonal relationships. IPT employs 2 strategies to achieve these goals. This therapy is done for 24 to 52 sessions and sometimes longer.

• The first is education about the nature of depressive disease. The therapist will emphasize that depressive disease is a common illness and that most people can expect to get better with treatment.
• The second is defining the problems (such as abnormal grief or interpersonal disputes). After the problems are defined, the therapist is able to help set realistic goals for solving these problems. Together various treatment techniques are utilized to reach these goals.

Cognitive Behavioral Therapy (CBT): This helps to alleviate depressive disease and reduce the likelihood it will come back by helping one to change the way of thinking. CBT uses 3 techniques to accomplish these goals. This therapy is done in 12-20 Sessions.

• Didactic component: This phase helps to set up positive expectations for therapy and promote cooperation.
• Cognitive component: Helps to identify the thoughts and assumptions that influence the behavior.
• Behavioral component: Employs behavior modifying techniques to teach new strategies for dealing with problems.

Behavioral Therapy (BT): This helps to modify the depressive behaviors through highly structured, goal-oriented therapy. BT uses 3 techniques to accomplish these goals. This therapy is done for 8-12 sessions.

• Functional analysis of behavior: Helps to define the behaviors that will be targeted for change.
• Selection of specific techniques: Various techniques can be employed to help modify the selected behavior, including relaxation training, assertion training, role playing, and time management tips.
• Monitoring behavior: Progress and program effectiveness can be monitored by logs and records.

COMPLIMENTARY THERAPIES

Many different complementary therapies are advocated by different groups and individuals. These include the following:

• Lifestyle changes such as diet, exercise, and stress reduction
• Biofeedback, and other relaxation therapies
• Physical therapies such as massage, reflexology, and acupuncture
• Environmental therapies such as aromatherapy and music therapy
• Spiritual or faith-based activities
• Interactions with other people and animals
• Yoga and Meditation

Most of these are safe for all or most people and may contribute to the overall well-being.

• They are not, however, a replacement for medical therapy known to be effective in most people.
• Check with the doctor/psychiatrist, especially if one is taking antidepressant medication, before starting any new diet or exercise program, new medications, or herbal preparations or supplements.

What Happens if we don’t treat Depressive Disease
Depressive is not a happy illness. Outside people look normal but inside people are under severe stress due to suffering from this disease. Depressive Disease can lead to the events like:

• Medical illness (stress of depressive disease causing headaches, obesity, malnourishment, heart disease, diabetes, decreased immunity and vulnerability to other medical diseases).
• Loss of a job due to decreased efficiency and loss of interest.
• Failure in exams due to lack of sustained concentration and memory over a period of time.
• Accidents due to lapse in concentration.
• Strained marital relations due to change in personality leading to breakups and divorces.
• Strained interpersonal relationships with colleagues and friends.

Without one's knowledge, this disease creeps into one's lives over a period of days and months and affects the day-to-day functioning. It affects one's Thoughts, Emotions, Behavior which lead to abnormal actions, attitudes and habits which in turn leads to changes in personality and thereby one's life.
It gradually affects one's Happiness, Pleasure, Satisfaction, Energy, Motivation, Ambition, Dreams, Self-Esteem, Hope, Love and above all the WISH TO LIVE.
At its worst, depressive disease may lead one to think about suicide. Hence it would be appropriate to say ' people don't commit suicides but have suicide attack or die by suicide'. Depressive disease is a burden for both the person and the family. Sometimes that burden can seem overwhelming.

IN AN EMERGENCY

If you think you may hurt yourself or attempt suicide, call THE MEDICAL EMERGENCY NUMBER - 911, 999, 108 or your local emergency number immediately or go to the Emergency Room or Casualty Department of your local hospital immediately. If you have a loved one who has harmed himself or herself, or is seriously considering doing so, make sure someone stays with that person. Take him or her to the hospital or call for emergency help.
 If you feel that you are suffering from an episode of depressive disease, you may talk about your feelings with a family member or a close friend. Communication is one of the keys to early diagnosis and treatment.
If you feel someone else is suffering from an episode of depressive disease, talk to that person.

• You may notice a person showing the features of depressive disease as mentioned above. If you see worthlessness, excessive guilt, hopelessness, or any suicidal thoughts, contact your doctor/psychiatrist immediately.
• With mild or moderately severe symptoms of short duration (weeks), it may be reasonable to contact a doctor/psychiatrist for an appointment.
• It is often helpful to accompany a family member or friend to the doctor's appointment and offer support as needed.
• If the person has severe symptoms, cannot care for himself or herself, or is threatening to harm himself or herself, seek immediate treatment in a hospital emergency department.

With severe depressive disease/disorder, hospitalization can be necessary. You may choose to come to the hospital for evaluation, or your family or friends may need to bring you to the hospital for evaluation in these circumstances:

• You have thoughts of hurting yourself.
• You have thoughts of hurting someone else.
• You are no longer able to care for yourself.
• You refuse to follow through with important treatment recommendations, such as taking your medication.

At the Doctor's/Psychiatrist's Office

Preparing for your appointment
You're likely to start by seeing your family doctor. However, in some cases when you call to set up an appointment, you may be referred directly to a psychiatrist — a medical doctor who specializes in diagnosing and treating depressive illnesses.
Because appointments can be brief, and because there's often a lot of ground to cover, it's a good idea to be well prepared for your appointment. Here's some information to help you get ready for your appointment, and what to expect from your doctor.
What you can do

• Write down any symptoms you've had, including any that may seem unrelated to the reason for which you scheduled the appointment.
• Write down key personal information, including any major stresses or recent life changes.
• Make a list of all medications, as well as any vitamins or supplements, that you're taking.
• Take a family member or friend along, if possible. Sometimes it can be difficult to soak up all the information provided to you during an appointment. Someone who accompanies you may remember something that you missed or forgot.
• Write down questions to ask your doctor.

Your time with your doctor is limited, so preparing a list of questions ahead of time will help you make the most of your time together. List your questions from most important to least important in case time runs out. For problems related to depressive disease, some basic questions to ask your doctor include:

• Is depression the most likely cause of my symptoms?
• Other than the most likely cause, what are other possible causes for my symptoms or condition?
• What kinds of tests will I need?
• What treatment is likely to work best for me?
• What are the alternatives to the primary approach that you're suggesting?
• I have these other health conditions. How can I best manage them together?
• Are there any restrictions that I need to follow?
• Should I see a psychiatrist or other mental health provider?
• Are there any possible side effects or other issues I should be aware of with the medications you're recommending?
• Are there any leaflets about depression that I can take home with me? What Web sites do you recommend visiting?

In addition to the questions that you've prepared to ask your doctor, don't hesitate to ask questions during your appointment at any time that you don't understand something.
What to expect from your doctor
Your doctor is likely to ask you a number of questions. Being ready to answer them may reserve time to go over any points you want to spend more time on. Your doctor may ask:

• When did you or your loved ones first notice your symptoms of depression?
• How long have you felt depressed? Do you generally always feel down, or does your mood fluctuate?
• Do you ever have suicidal thoughts when you're feeling down?
• How severe are your symptoms? Do they interfere with your daily life or relationships?
• Do you have any biological relatives with depression or another mood disorder?
• What other mental or physical health conditions do you have?
• Do you drink alcohol or use illicit drugs?
• How much do you sleep at night? Does it change over time?
• What, if anything, seems to improve your symptoms?
• What, if anything, appears to worsen your symptoms?

Tests and diagnosis

Because depressive disease is common and often goes undiagnosed, some doctors and health care providers may ask questions about your mood and thoughts during routine medical visits. They may even ask you to fill out a brief questionnaire to help check for depression symptoms.
When doctors suspect someone has depressive disease they generally ask a number of questions and may do medical and psychological tests. These can help rule out other problems that could be causing your symptoms, pinpoint a diagnosis and also check for any related complications. These exams and tests generally include:

• Physical exam. This may include measuring your height and weight; checking your vital signs, such as heart rate, blood pressure and temperature; listening to your heart and lungs; and examining your abdomen.
• Laboratory tests. For example, your doctor may do a blood test called a complete blood picture (CBP), Blood Glucose (RBS), or test your thyroid (TSH) to make sure it's functioning properly.
• Psychiatric evaluation. To check for signs of depressive disease, your doctor or psychiatrist will talk to you about your thoughts, feelings and behavior patterns. He or she will ask about your symptoms, and whether you've had similar episodes in the past. You'll also discuss any thoughts you may have of suicide or self-harm. Your doctor may have you fill out a written questionnaire to help answer these questions.

HOW TO HELP ONESELF

Once you are being treated for depressive disease/disorder, you can make lifestyle changes and choices that will help you through the rough times and may prevent depressive disease/disorder from returning:

• Try to identify and focus on activities that make you feel better. It is important to do things for yourself.
• Don't isolate yourself. Take part in activities even when you may not want to. Such activity may actually make you feel better.
• Talk with your friends and family and consider joining a support group. Communicating and discussing your feelings is an integral part of your treatment and will help with your recovery.
• Try to maintain a positive outlook. Having a good attitude can be beneficial.
• Regular exercise and proper diet are essential to good health.
• Try to get enough rest and maintain a regular sleeping pattern.
• Avoid drinking alcohol or using any illicit substances.
• Yoga and meditation are also helpful.

HOW TO HELP SOMEONE WITH DEPRESSIVE DISORDER

People with depressive disease often don't see the point of doing anything and may feel that no one can really help them. Helping someone who isn't ready to recognize they need help would be very difficult. It’s not always easy to know how to help someone who may be experiencing depressive disease. It can be hard to know what to say or do. Here are some tips. 

• Talk to the person about how they're feeling.
• Listen to what they're saying - sometimes, when a person wants to talk, they're not always seeking advice, but just need to talk about their concerns. Make it clear they have your full attention and you are listening properly. You may like to save any suggestions for a later discussion.
• Maintain eye contact and sit in a relaxed position - positive body language will help you both feel more comfortable. 
• Use open-ended questions such as 'so tell me about...?’ which require more than a 'yes' or 'no' answer. This is often a good way of starting a conversation.
• If the conversation becomes difficult or the person gets angry: stay calm; be firm, fair and consistent; admit if you are wrong and don't lose control. 
• Often, just spending time with the person lets them know you care and can help you understand what they're going through.
• Encourage the person to seek professional help from their family doctor or a professional. 
• Take care of yourself. Supporting someone with depression can be demanding, so make sure you take some 'time out' to look after yourself.

DO’s - one can help someone by: 

• Spending time talking about their experiences
• Indicating that you've noticed a change in their behavior
• Letting them know you're there to listen without being judgmental 
• Suggesting they see a doctor or psychiatrist
• Assisting them to make an appointment and/or going with them to see a doctor or psychiatrist 
• Asking how their appointment went
• Talking openly about depression and assisting them to find information 
• Encouraging them to exercise, eat well and become involved in social activities
• Keeping in touch and encouraging close friends and family to do the same.

DON'T’s - 

• DON'T pressure them to 'snap out of it', 'get their act together' or 'cheer up'
• DON'T tell them to 'Think Positively'
• DON'T stay away or avoid them
• DON'T tell them they just need to stay busy or get out more
• DON'T pressure them to party more or wipe out how they're feeling with drugs or alcohol 
• DON'T assume the problem will just go away.