• Approximately 10% of ex-serving Navy, Army and Air force members were affected by depression in the last year.
• The Depression Anxiety and Stress Scale (DASS-21) can be used to identify depressive symptoms and their severity.
• Cognitive behavioural therapy (CBT) and interpersonal therapy have strong evidence for treating depression. Both are available through Open Arms counselling.

Key characteristics

Persistent low mood and/or a loss of interest or pleasure in activities are key characteristics of major depression. A person with depression will also experience a number of symptoms such as:

• changes in appetite and/or weight
• insomnia or hypersomnia
• psychomotor agitation or retardation
• low energy or fatigue
• trouble concentrating or making decisions
• feelings of worthlessness or excessive guilt
• recurrent thoughts of death or suicidal thoughts or behaviour

Individuals with depression may not present with a primary complaint of depression. Many will seek help for insomnia, or pain, or appear excessively worried about physical aches and pains. Veterans may complain of feeling irritable, sad, or having no feelings at all.

In assessing the presence of depression, clinicians should take note of:

• facial expressions
• general demeanour

For a diagnosis of major depression, symptoms must:

• be present for most of the day and/or nearly every day
• for at least two weeks
• represent a significant departure from normal functioning

Depression can range from mild to severe, and may become chronic or relapse. When episodes of depression occur in rotation with episodes of mania, this may form part of a bipolar mood disorder.

Some people will experience consistent feelings of low mood for two years or more, but not have symptoms severe enough to be diagnosed with major depression. This condition has been known as dysthymia and is relatively common in veterans. In DSM-5, dysthymia and chronic major depression are combined in a new diagnosis called Persistent Depressive Disorder.

Prevalence

Depressive disorders are also common in civilian and veteran populations.  The prevalence rates do differ across cohorts and studies.

In the civilian population:

• 15% of Australians will experience a depressive disorder (i.e. major depression or dysthymia) at least once in their lifetime (ABS, 2007). 
• 8.9% of Australians reported having depression or feelings of depression within a 12-month period (ABS, 2015). 

In the veteran population:

• 11.2% of ex-serving Navy, Army and Airforce members had experienced depression within a 12-month period (Van Hooff et al., 2018).
• 10% of Australian Gulf War veterans had experienced major depression within a 12-month period (Ikin et al 2004).
• 25% of Australian Vietnam veterans experienced depression at least once within their lifetime (O'Toole et al. 1996).

Several factors place veterans at increased risk of depression, including:

• military-specific factors such as war-related traumatic events
• discharge and the transition to  civilian life
• more generic stressors such as marital breakdown

Female veterans are at greater risk of experiencing depressive episodes than males (as in the general population). It is worth keeping in mind given the increasing proportion of women in the younger cohort of veterans.

Screening and assessment

Screening for depression should include two questions on mood and interest. As recommended by the UK’s National Institute for Health and Care Excellence (NICE) guidelines (2009). These are:

• During the last month, have you often been bothered by feeling down, depressed, or hopeless?
• During the last month, have you often been bothered by having little interest or pleasure in doing things?

If  ‘yes’ is answered to either question conduct further assessment. Assessing mental state, as well as social, occupational, and interpersonal difficulties .

A number of self-report measures are available to assess the severity of depressive symptoms. These include the:

• Depression Anxiety and Stress  Scale (DASS-21). This scale helps track depressive symptoms as well as counselling outcomes 
• Hamilton Depression Scale (HAM-D)
• Beck Depression Inventory (BDI-II)
• Hospital Anxiety and Depression Scale (HADS).
• Patient Health Questionnaire (PHQ-9)

Risk assessment – self-harm/suicide and harm to others

Depression is a significant risk factor for suicide. Veterans with depression should be screened using direct and unambiguous questions such as:

• Are there times when things seem so hopeless that you think about killing yourself?
  • (If yes), do you have a plan of how you might do this?
  • (If yes), do you have access to… (check means and opportunity)?
• Have you ever harmed yourself or tried to kill yourself in the past?
• Do you live alone (or unsupervised)?
• Do you use amphetamines, alcohol, or other substances?

The above questions can be reframed to assess risk of harm to others. E.g. 'Are there times when things seem so hopeless that you think about ending the lives of others around you?'

Be aware that many symptoms of depression, such as lack of motivation, psychomotor retardation, and apathy initially reduce the risk of suicide and harm to others. However, practitioners should be alert to the risk of harm to self or others as clients start to recover. Clients may still feel hopeless, but have regained enough energy to act on suicidal or homicidal thoughts.

Where there are issues of potential harm to self or others, practitioners should be aware of their duty of care to both the veteran and others. As set down by the ethical standards established by their professional group.

Veterans with depressive disorders may have fluctuating or continued severe distress and significant potential for self-harm. For a portion of veterans, particularly younger veterans, impulsive self-destructive and aggressive behaviours such as dangerous driving are common.

Psychological intervention

Cognitive behavioural therapy, (CBT) and interpersonal therapy have Level I evidence for their efficacy in treating major depression (Malhi et al., 2013). There is also an emerging evidence base for alternative psychological interventions such as mindfulness-based therapies.

Cognitive behavioural therapy (CBT)

Mental health practitioner-delivered CBT should be considered for veterans with moderate or severe depression. Talking to a veteran, together with the veteran’s family, about his or her depression is the start of treatment.

Specific CBT techniques for targeting depression are:

• Structured problem solving – this can help the veteran address feared problems that they otherwise might find overwhelming.
• Activity scheduling – this involves scheduling a balance of pleasant, achievement-related and physical activities. This assists with circumventing rumination, and increases positive and rewarding experiences. By targeting symptoms such as low motivation and mood, lack of energy and withdrawal from activities and people.
• Cognitive therapy – this assists in identifying and challenging excessively negative thoughts. Such as poor thoughts about oneself, one’s future, or the loss of a loved one or something highly valued. The veteran learns to challenge the accuracy of those thoughts and identify more balanced and helpful interpretations of events, and perceptions of themselves, others and the world.

Psychoeducation and self-management strategies

When providing psychoeducation it is important to explain and demystify the veteran’s symptoms. This helps the veteran regain a sense of control and a sense of hope. It is also important to encourage the veteran to do the following:

• Prioritise spending time and reconnecting with their social supports. E.g. sympathetic family members  and friends, local interpersonal community activities. There is strong evidence that social support is a key factor in preventing deterioration of symptoms and in promoting recovery.
• Maintain (or re-establish) their daily routine and current roles. E.g. work, family. This is particularly important for veterans who have a lot of unstructured time or have prominent or long-standing avoidance symptoms. This may include a simple exercise routine and engaging in planned pleasant events.
• Reduce substance use. While alcohol and drugs may alleviate distress in the short term, they inhibit recovery. This is a significant issue amongst veterans, with high comorbidity between depression and substance use issues. Early advice on reducing substance use is effective.

Interpersonal therapy

People with depression can be easily upset by other people’s comments, and experience significant interpersonal difficulties that contribute to or exacerbate depression. Interpersonal therapy (IPT) aims to help the veteran understand and resolve these difficulties. IPT has been less thoroughly researched than CBT. Early evidence suggests that the two therapies are broadly similar in effectiveness (Cuijpers et al., 2011). Therefore, the decision to progress with one over the other will come down to the preferences of both the veteran and practitioner. There is also some early evidence that IPT is comparably effective to antidepressants in preventing the development of depression (Lampe, Coulston, & Berk, 2013). Evidence is insufficient at present to recommend its use as a prophylactic.

Mindfulness-based interventions

Mindfulness-based interventions aim to:

• increase self-awareness 
• encourage distance from thoughts and emotions so that unpleasant events cause less distress.

By limiting emotional investment, extreme negative reactions such as depression may be reduced. While mindfulness-based therapies are widely practised, they have been less thoroughly researched. These therapies appear to be more effective than placebo interventions (Hofmann, Sawyer, Witt, & Oh, 2010). It is not clear how mindfulness compares with established treatments for depression such as CBT or IPT. Mindfulness approaches should be considered only for individuals whose depression has not responded to CBT or IPT. Mindfulness-based therapies, as well as CBT, are recommended for preventing depressive relapse and/or recurrence (Malhi et al., 2013).

Psychological treatment setting and duration

Mild to moderate depression can be treated in an outpatient setting. This does not usually require admission to a psychiatric hospital unit. Requirements for admission depend on the severity of depression and the risk of self-harm and suicide. Psychological treatment for mild to moderate depression should focus specifically on the depression for a period of 6-8 sessions over 10-12 weeks. In more difficult and complex cases, a longer course of psychological treatment may be required.

Group treatment programs

Open Arms group treatment program Beating the blues is a CBT based program that aims to help veterans understand and manage depression. They will:

• understand the signs and symptoms, situations and thinking patterns that contribute to depression
• challenge unhelpful thinking patterns and behaviours
• learn techniques to manage stress and depressed moods

Pharmacological interventions

Medication is usually not recommended for mild depression, psychological interventions are preferred. Antidepressants may be considered for veterans with moderate or severe depression adjunctive to or followed by psychotherapy. Those with chronic or severe symptom presentations should be offered combined psychotherapy and pharmacotherapy as first-line treatment.

Recommended options as the first line of pharmacotherapy include:

• selective serotonin reuptake inhibitors (SSRIs)
• noradrenergic reuptake inhibitors (NaRIs)
• norepinephrine-dopamine reuptake inhibitors (NDRIs)
• noradrenergic and specific serotonergic antidepressants (NaSSAs)

Monoamine oxidase inhibitors (MAOIs) or older-generation antidepressants such as the tricyclics (e.g. Deptram) may be more effective in treating severe or treatment-resistant depression but pose a greater risk of overdose and should be prescribed with caution.

Clinicians should consider a range of factors when choosing pharmacological interventions, including:

• patient symptom profile
• severity
• side effects and tolerability
• cost
• suicide risk
• clinician’s own experience

Electroconvulsive therapy

Electroconvulsive therapy (ECT) remains an important antidepressant treatment. Mainly in the context of severe depression. Severe depression is characterised by melancholia, psychotic features and/or high suicide risk. ECT is only to be administered in a psychiatric setting with accredited facilities and practitioners. There are some medical contraindications to ECT and the general anaesthetic that it requires.

When effective, ECT provides short-term improvement. Subsequent maintenance antidepressant medication is usually required. Cognitive impairment for a time around the treatment is a side effect of ECT. However there is no objective evidence of impairment persisting after a course of treatment. Maintenance ECT has not been well researched. It is used on occasions where medications and psychotherapy have failed as maintenance treatments. The decision to use ECT should be taken only after careful clinical review, and documented informed consent is given.

See also