“When we talk about depression, probably the most common type that we would see in general practice would be major depressive disorder or major depressive episode,” says Dr Riani Grosskopf, “but the thing to keep in mind with depression is that it is often part of a different type of disorder.”
The Dublin-based GP, who says mental health assessments are required for patients who present with depression-related symptoms such as hopelessness and sleep disturbances for longer than two weeks, also says it’s important not to negate other possible contributing factors to the condition.
“What we often see in general practice is that there is an overlap with chronic diseases so it makes sense that you see the person as a whole, you can’t just put one name on it and miss out on the rest,” she says.
Such is the case for 25-year-old Emma O’Sullivan whose depression was a symptom of her eating disorder.
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“For me, it was intertwined with eating problems,” says the Cork native who was first diagnosed with depression and anxiety in her mid-teens, “so it really showed up because of the eating disorder symptoms, from that stemmed the depression and anxiety.”
The 25-year-old’s mental health struggles were so unbearable that she ended up being hospitalised for half a year.
While in hospital, her treatment plan included taking antidepressants. “I wasn’t prescribed them right away,” she says, “I was in the hospital for about six months with anorexia. During that time, they prescribed me Prozac. I believe it was a low dose, so 5[mg] and then it was increased to 10[mg] and then increased further and further.
“I think I remember for a day or two feeling a tiny bit more happy, and then it just plateaued where I felt absolutely no improvement even though the dose went up. I was still as anxious and depressed as I was before.”
The mental health advocate also says she struggled to find emergency care due to her apprehension about taking antidepressants. “I didn’t want to take medication,” she explains, “but you’re put into a situation where you are forced really into taking medication or you can’t really get help. Their way of thinking is if you’re not engaging in medication, you’re not engaging with their treatment plans.”
According to Dr Grosskopf, “you don’t see someone for the first time and just give them a script”, and she says it is of the utmost importance for clinicians to be alert to the condition and get as much information as possible from their patient in order to provide them with the most suitable treatment plan.
“We definitely talk about shared decision making,” she says, “because some people are more resistant to the thought of taking medication. So we often look at a combined approach of looking at lifestyle and things that I can do on a basic perspective to improve. Things like my sleep hygiene, my exercise, low or no alcohol. But then we also look at the benefit of psychotherapy and treatments like cognitive behaviour therapy [CBT] that can be hugely beneficial for depression with or without medication.”
Dublin native Conor Stone attributes his current mental state to the CBT and psychotherapy, despite taking antidepressants for two consecutive years. “I definitely credit therapy, CBT, meditation and exercise more than I do antidepressants with being in a better place now, but what I would say is that the Fluoxetine [Prozac] allowed me to engage with those things in a way that I wasn’t able to before,” says the 26 year old.
Stone started having panic attacks in January 2018, shortly after retiring from hurling. When he was initially prescribed antidepressants, he decided against taking them. But after moving to the UK that September, medication was his last resort after he experienced burnout.
“Here [in London], I was prescribed Sertaline,” he explains, “I was on it for three months. It kind of made me more energised, but it probably made me more wired and increased my anxiety, so my depression was maybe a bit lower and my anxiety was a bit high and so I transferred across to Fluoxetine [Prozac] and that quite suited me, so then I was on it all the way until the summer of 2021.”
The London-based tech worker says he had regular check-ups with his GP in the two years that he was on medication for his mental health and this continued until he was weaned off the drug. “Throughout that time I had regular check-ins with my GP, and then when I was signing off them, they helped me come off them gradually,” he says, “so they reduced my dosage over the course of a month. We went from my full dose on to a half dose and then a quarter dose over that period of time, and then I was completely off it then. We would never drop a dose before knowing that I stabilised on that dose.”
Dr Lorcan Martin, consultant general adult psychiatrist and vice-president of the College of Psychiatrists of Ireland, says tapering off antidepressants should be done only under medical supervision.
“Some antidepressants will require gradual reduction to prevent discontinuation symptoms, whereas others can be stopped pretty much without difficulty,” he says. “It’s usually done over a number of weeks, but it can be longer if the person is on a higher dose or particularly sensitive to discontinuation. You have to look at the individual, the medication they’re on and the dose that they’re on of that particular medication.
“Stopping them too early can often lead to relapse and if you do it too suddenly, it can lead to discontinuation issues with some antidepressants so it should always be done under supervision of a doctor,” he adds.