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Depression in Tough Economic Times –
Emotional & mental well-being

August 2009 – Vol. 13, No. 8

Editor: Janet M. Pollard, MPH

“Economic turmoil (e.g., increased unemployment, foreclosures, loss of investments, and other financial distress) can result in a whole host of negative health effects – both physical and mental. It can be particularly devastating to your emotional and mental well-being. Although each of us is affected differently by economic troubles, these problems can add tremendous stress (PDF), which in turn can substantially increase the risk for developing such problems as: depression, anxiety, compulsive behaviors (over-eating, excessive gambling, spending, etc.), and substance abuse.”¹

This issue of HealthHints will focus on how to identify decreased mental and emotional well-being, particularly depression with onset within three months of a stressful event, like financial or job loss. We will address self-care and treatment options and provide resources you can turn to for help.

Warning Signs & Symptoms: When you’re not yourself

“It is important to be aware of signs that financial problems may be adversely affecting your emotional or mental well being – or that of someone you care about.” These signs include:

• persistent sadness/crying;
• excessive anxiety;
• lack of sleep/constant fatigue;
• excessive irritability/anger/frustration/intolerance;
• increased drinking;
• illicit drug use, including misuse of medications;
• difficulty paying attention or staying focused;
• apathy – not caring about things that are usually important to you, withdrawing from others;
• not being able to function as well at work, school, or home;
• loss of appetite;
• memory or concentration problems (forgetfulness or vagueness);
• mood swings, over-reaction to small things;
• lower sex drive and performance;
• loss of direction, sense of powerlessness;
• muscle tension or pain; and/or
• other physical symptoms (e.g., heartburn, skin rashes, stomach pains).^1,2

Job or financial loss can increase a person’s risk for anxiety and depression.³ In fact, “research has shown that as one repeatedly reacts to events that are stressful, the disastrous effects on the body accumulate so that the individual becomes increasingly susceptible to emotional problems, accidental injuries, physical illness, and behavioral disorders.”⁴ It is important to develop positive strategies and seek help if emotional reactions are severe or persist beyond a normal period of adjustment (usually 2–3 weeks), there is an inability to function and carry on day-to-day tasks, or alcohol or other substances (illicit drugs or abuse of medications) are being used to “self-medicate” or cope.²

Depression: When life events lead to depression

There is no single cause of depression.⁵ Many factors play a role including genetics, environment, medical conditions, life events, and the way people react to things that happen in their lives.⁵ There are several types of depression, including:

• Major depression (also called clinical depression) – a “serious condition characterized by a persistent sad mood, feelings of worthlessness or guilt, and the inability to feel pleasure or happiness. Major depression typically interferes with day-to-day functioning like eating and sleeping,”⁶ but it is shorter-lasting than dysthymia⁵ (see below). While some people may have major depression only once in a lifetime, others may experience it repeatedly.⁷
• Dysthymia – a longer-lasting, but less severe form of depression, “dysthymia may be diagnosed if sadness or irritability is not as severe, but continues for a year or longer.”⁶
• Bipolar adjustment – “another type of mood disturbance, [bipolar adjustment] is characterized by episodes of low-energy depression (sadness and hopelessness) and high-energy mania (irritability and explosive temper).”⁶
• Adjustment disorder – another form of depression and the one we will focus on in this newsletter, is called adjustment disorder with depressed mood (sometimes called situational or reactive depression).⁸ This diagnosis refers to a depressive reaction to a specific life event (e.g., job loss, financial loss, or other loss like divorce or death), when adjusting to the loss takes longer than normally expected or is more severe than expected and interferes with a person’s daily activities.⁵ You can also have adjustment disorder with anxiety in which symptoms may include nervousness, worry, difficulty concentrating or remembering things, and feeling overwhelmed – or adjustment disorder with mixed anxiety and depressed mood.⁹

“…Distress is a common and natural response to unexpected events that involve significant loss and change. In some cases, this reaction may be similar to grieving.”² Financial loss may mean seeking income support, revising retirement plans, or cutting down on household spending; some events may mean making extreme changes to the lifestyle in which one lives.² Thus, job and financial loss can be factors in the development of this type of depression or anxiety.

How do you know it’s not just stress, but something more? “People can experience stress in different degrees, from mild to severe. ‘Just enough’ stress can be a good thing and indeed critical to survival. However, when this stress response fails to switch off and reset itself after a challenging situation has passed, or if it worsens to the point of distraction, it can lead to more significant psychological problems and even worsen some medical conditions. That is the point at which an adjustment disorder or more severe problems can develop.”¹⁰

How is depression different from regular sadness? “Depression is more than occasionally feeling blue, sad, or down in the dumps…. Depression is a strong mood involving sadness, discouragement, despair, or hopelessness that lasts for weeks, months, or even longer. It interferes with a person’s ability to participate in normal activities. Depression affects a person’s thoughts, outlook, and behavior as well as mood. In addition to a depressed mood, a person with depression can also feel tired, irritable, and notice changes in appetite.”⁵ Depression can cause other physical symptoms, too. Some people have an upset stomach, weight gain or loss, headaches, and sleeping problems when they’re depressed.⁵

“When someone has depression, it can cloud everything. The world looks bleak, and the person’s thoughts reflect that hopelessness and helplessness. People with depression tend to have negative and self-critical thoughts. Sometimes, despite their true value, people with depression can feel worthless and unlovable. Because of feelings of sadness and low energy, people with depression may pull away from those around them or from activities they once enjoyed. This usually makes them feel more lonely and isolated, making the depression and negative thinking worse. Depression can be mild or severe. At its worst, depression can create such feelings of despair that a person thinks about suicide (PDF).”⁵

“Most of the time, people adjust to changes within a few months. But if you continue to feel down or self-destructive, you may have an adjustment disorder. An adjustment disorder is a type of stress-related mental illness. You may feel anxious or depressed or even have thoughts of suicide (PDF). You may not be able to go about some of your daily routines, such as work or seeing friends. Or you may make reckless decisions. In essence, you have a hard time adjusting to change in your life, and it has serious consequences.”⁹

In addition to the emotional and physical symptoms listed above, adjustment disorder may affect your actions or behaviors, including such reactions as: fighting, reckless driving, ignoring bills, avoiding family and friends, poor school or work performance, skipping school or work, and vandalism.⁹

Adjustment disorders are characterized by:

• having emotional or behavioral symptoms within three months of a specific stressor occurring in your life, and/or
• having serious symptoms involving severe distress or an inability to function well in your daily life.

Symptoms of adjustment disorder may be acute – going away on their own in 6 months or less, especially if you actively follow self-care measures (see below); or chronic – lasting longer than 6 months, where symptoms continue to bother you and disrupt your life.⁹ Some individuals “may develop a chronic adjustment disorder because they experience multiple causes of distress, one right after another…. Chronic adjustment disorders may become a more serious mental disorder (for example major depression).”¹¹ “Professional treatment can help symptoms improve and prevent the condition from continuing to get worse.”⁹

Taking Care: Self-care & treatment

Although one method may not work for all people, there are some key factors that help individuals who are dealing with severe stress and adjustment disorders. These methods include: social support, “talk” therapy, medications, and self-care.

Social Support. Though there is no known way to prevent adjustment disorder, strong family and social support can help a person work through a particularly stressful situation or event.^8,12 Having or building a strong network of social support can be an important factor for resiliency and recovery in tough economic and other stressful times. Research indicates that ““both older and unmarried individuals may be especially vulnerable to the negative mental health consequences of job loss. This finding regarding marital status is consistent with other unemployment studies that have shown that social support can buffer the health effects of job loss.”¹³ So, talk things over with caring family members and friends.⁹ It is especially important to respond to this situation as a family. Discuss with your spouse and older children what the situation is and the impact of these changed circumstances (e.g., decreased household spending). Be sure to reassure your children, and allow them to express their feelings. Think about and communicate what steps you can take to ensure life remains as normal as possible and what enjoyable activities you can still do as a family.² “It makes sense to take care of yourself so that you can provide for others,”² but don’t hesitate to seek out support for yourself.⁹ Find a support group geared toward your situation. Find support from a faith community.⁹ Avoid isolation. Though you may not feel like facing others, avoiding isolation is important in recovery.¹⁰

“Talk” Therapy. Treatment for depression can include “talk” therapy, sometimes called psychotherapy. “Talk therapy with a mental health professional is very effective in treating depression. Therapy sessions can help people understand more about why they feel depressed and ways to combat it.” “Talk therapy may involve only the individual patient, but it can include others, for example, family or couples…. Depending on the severity of the depression, treatment can take a few weeks or substantially longer. However, in many cases, significant improvement can be made in 10 to 15 sessions.”¹⁴

Medication. Sometimes, doctors will prescribe medications for depression either alone or along with talk therapy. “There are many effective medications available to treat depression today. Depression involves an imbalance of chemicals in the brain, and medications work on the brain to bring these chemicals back into balance. There is no more shame in taking medication for depression than there is in taking medication for diabetes, asthma, or other medical conditions.”¹⁵ When prescribing medicine, your doctor will carefully monitor you to make sure you get the right dose. The doctor will adjust the dose as necessary. It can take a few weeks before you feel the medicine working. Because every person’s brain is different, what works well for one person might not be good for another.⁵ Keep in communication with your doctor about side effects, what works, and what doesn’t work until you find the right dosage and/or medication for you.

Self-Care. In addition to building and utilizing your social support network of family and friends and avoiding isolation, here are some other self-care measures that may help you cope in times of distress:

• Try to keep things in perspective. Recognize the good aspects of life, and retain hope for the future.¹
• Base your self-worth on who you are (valuable citizen, family member, etc.) – not what you do (e.g., job, financial status). If a person defines their value by their job or financial status, they may be more vulnerable¹⁶ to negative mental and emotional health outcomes. If you have difficulty finding your self-worth, turn to your faith community or support groups to help you define your self-worth.
• Know that you are not alone. “Personal finance was rated by workers in one study as the number one source of stress…,”¹⁷ and “the media often reports that at any point in time about one-third of American adults are concerned about their ability to pay the next month’s bills.”¹⁷ “About one in four adults suffer from a diagnosable mental disorder in a given year.”¹⁸
• Be proactive. Developing new employment skills can provide a practical and highly effective means of coping and directly addressing financial difficulties.¹ Write down the problems causing you worry or stress. Write down your expenses so you can plan and prioritize. Begin by tackling one problem that is specific and has the potential to be solved.²
• Keep healthy. A healthy diet, along with regular exercise and sleeping routines, can be positive steps toward both physical and mental well-being.⁹
• Participate in healthy mood-boosting activities, which can include: exercise, dancing, journaling (writing down your worries), or art or other enjoyable hobbies.^1,2,5
• Avoid drugs and alcohol.²

“People who are depressed shouldn’t wait and hope it will go away on its own because depression can be effectively treated.”⁵ The best approach is early treatment, which can reduce the severity and duration of symptoms and teach new coping skills.⁸ “The healthiest thing you can do for yourself and your loved ones is to be alert to changes in your feelings and moods, and feel free to talk about them and seek appropriate assistance¹⁵ (e.g., counselor, psychologist, psychiatrist, support group, etc.).

Family, friends, or others “need to step in if someone seems severely depressed and isn’t getting help.”⁵ See here for a list of financial and mental health resources that can help (PDF).

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A Note to Employers: Employee Wellness – Research points to profits

“Mental health disorders are an expensive problem – direct medical costs are estimated at more than $83 billion per year for depression and $63 billion for anxiety…. Depression and anxiety also carry costs in reduced productivity, not only through missed work days but also through ‘presenteeism’ – days when employees are present but working at less than full capacity. These disorders may also have a ‘ripple effect,’ leading to low morale and other problems in the workplace. Faced with rising health care costs, companies may be tempted to limit mental health benefits.”¹⁹

A better approach, where people and profits are concerned, “is to provide employees with access to high-quality mental health diagnosis and treatment services.”¹⁹ “Adequate evaluation and treatment of depression and anxiety lowers other medical costs and avoids missed work days and reduced productivity.”¹⁹ In fact, “the costs of treatment for depression may be fully offset just by the savings from a reduction in missed work days – not even counting gains in productivity or reductions in general medical costs. Ensuring high-quality mental health services – preferably delivered by a psychiatrist, working in cooperation with the patient’s primary care doctor – is a key part of the equation.”¹⁹

“It pays for employers to be interested in the wellness of their employees. For every dollar spent on mental health and substance abuse treatment, $11.54 is saved in social services costs. Employers find that there is a five-to-one return for every dollar spent on an employee assistance program, with a substantial savings on health care benefits.”¹⁷

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This document is meant for educational purposes only and is not intended to replace the advice of your doctor or other health care provider.

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References:

1. Substance Abuse and Mental Health Services Administration (2009). Getting through tough economic times [on-line]. Retrieved June 19, 2009.
   From http://www.samhsa.gov/ECONOMY/.
2. Beyond Blue (2009). Taking care of yourself after retrenchment or financial loss [on-line]. Retrieved June 19, 2009.
   From http://www.beyondblue.org.au/index.aspx?link_id=4.1092.
3. Price RH, Choi, JN, and Vinokur, AD (2002). Links in the chain of adversity following job loss: How financial strain and loss of personal control lead to depression, impaired functioning, and poor health. Journal of Occupational Health Psychology 7(4), 302-312.
4. Kim, J, Garman, ET, and Sorhaindo, B (2003). Relationships among credit counseling clients’ financial well-being, financial behaviors, financial stressor events, and health [on-line]. Retrieved June 16, 2009. From http://6aa7f5c4a9901a3e1a1682793cd11f5a6b732d29.
   gripelements.com/pdf/vol1427.pdf.
5. Nemours Foundation (2007). Depression [on-line]. Retrieved June 16, 2009. From http://kidshealth.org/teen/cancer_center/feelings/depression.html.
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   1&ps=107&cat_id=145&article_set=21584.
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8. WebMD (2009). Mental health: Adjustment disorder [on-line]. Retrieved June 16, 2009. From http://www.webmd.com/mental-health/mental-health-adjustment-disorder.
9. Mayo Clinic (2009). Adjustment disorder [on-line]. Retrieved June 16, 2009. From http://mayoclinic.com/health/adjustment-disorders/DS00584.
10. Mayo Clinic (2008). Normal stress vs. adjustment disorder: What’s the difference? [on-line]. Retrieved June 16, 2009. From http://mayoclinic.com/health/adjustment-disorder/AN01768.
11. National Cancer Institute (2009). Normal adjustment and distress [online]. Retrieved June 16, 2009. From http://www.cancer.gov/cancertopics/pdq/supportivecare/
    adjustment/Patient/page4.
12. U.S. National Library of Medicine (2009) Adjustment disorder [on-line]. Retrieved June 16, 2009. From http://www.nlm.nih.gov/medlineplus/ency/article/000932.htm.
13. Gallo WT, Bradley EH, Siegel M, and Kasl SV (2000). Health effects of involuntary job loss among older workers. The Journal of Gerontology Series B: Psychological Sciences and Social Sciences 55:S131-S140.
14. American Psychiatric Association (2005). Let’s talk facts about depression [on-line]. Retrieved June 16, 2009. From http://www.medem.com/medlib/article/
    ZZZZJDP487C.
15. Depression and Bipolar Support Alliance (2006). Coping with unexpected events: Depression and trauma [on-line]. Retrieved June 16, 2009. From http://www.dbsalliance.org/site/PageServer?pagename=about_publications_trauma.
16. American Psychiatric Association (2009). Getting help for distress in troubled economic times [on-line]. Retrieved June 19, 2009. From http://www.medem.com/
    medlib/article/ZZZMAT7A4KD.
17. Garman TE, Leech IE, and Grable JE (1996). The negative impact of employee poor personal financial behavior on employers [on-line]. Financial Counseling and Planning 7: 157-168. Retrieved June 17, 2009. From http://www.afcpe.org/publications/journal-articles.php?volume=131&article=47.
18. National Institute of Mental Health (2009). The numbers count: Mental disorders in America [on-line]. Retrieved June 24, 2009. From http://www.nimh.nih.gov/health/
    publications/the-numbers-count-mental-disorders-in-america/index.shtml.
19. American College of Occupational and Environmental Medicine (2009). Good treatment for depression and anxiety means profits for employers [on-line]. Retrieved June 16, 2009. From http://www.medem.com/medlib/
    article/ZZZMZVAWCGE.