By Terry Portis, President of the Brain Injury Association of NC
This article sponsored by Charles Monnett III and Associates
She sat across from her friend quietly as they drank a mid-morning coffee. Now and then she would look up and sigh. “Every day seems longer than the day before,” she said. It’s a chore, and I don’t see things getting any better. Some days I don’t even want to get out of bed, and when I do, I don’t have the energy or interest in doing anything. And then I see the mess the house is in and that makes me feel worse. Sometimes I feel as though I am paralyzed. It’s so hopeless. I can’t do anything. I feel like I am stuck in quicksand at the bottom of a pit.
This lady is the caregiver for a teenage son who has sustained a brain injury. Her dreams for her son of college, marriage, a great job, and grandchildren all were smashed when their family car smashed against a tree two years ago. Her goals now revolve around her hopes that he can regain his toileting ability and that he want scream out in public as much. Life has changed dramatically and depression is one of the results.
The purpose of this article is to give a brief overview of depression for persons who have sustained a brain injury and their family members. It is not intended to be a substitute for the care that a family physician or trained professional counselor can give. If you or your loved one is struggling with depression, see a qualified professional.
I. Depression is common after brain injury
Depression can strike you at any age, whether you are six or seventy-six. It occurs when people are in the midst of a crisis and when people are not in a crisis. One out of eight people can be expected to receive treatment during their lifetime for depression.
When brain injury is present, depression is ten times as likely to occur. It is the most commonly reported emotional disturbance among people who have sustained a serious brain injury (Hibbard, M., Uysal, S., Kepler, K. et al. 1998). A person may not say the words “I am depressed,” but may say something like “Since my injury there is a feeling of gloom over me,” or “I have felt down for months and can’t seem to shake it.” People who are survivors of brain injury may feel this way and family members of persons with brain injury may also feel this way.
II. Depression is normal
Let me emphasize, depression is a normal and natural emotion, and we would be abnormal not to experience it when the causes for depression are present. It is not a sin or a sign of weakness. Life is difficult enough, through in a brain injury and it becomes even more difficult.
When thinking about depression, keep in mind that:
1. It can be a healthy response to what is taking place in a person’s life. It is a normal reaction to what is taking place physically and psychologically. Trauma is a shock to one’s system, depression is a normal reaction to that trauma.
2. Depression can be a scream, a message telling us that we have neglected some area of our life. We must listen to depression, because it has something to tell us. Sometimes caregivers are so busy taking care of a family member that they forget to take care of themselves. After a TBI, a family may become fatigued, isolated and under financial stress. All of these factors contribute to the start of depression and can cause it to continue. Depression screams to the caregiver that it is time to spend some time taking care of yourself.
3. Depression is a warning system that we are moving toward deep water. It is a protective device that can remove us from stress and give us time to recover if we use it in that way. If you have people who can help you, this is the time to let them. This is not to say that we are to linger in depression, we should discover its purpose and move on in life through the help of friends, relatives and caring professionals.
III. Indicators of depression
1. A person feels hopelessness, despair, sadness and apathy.
It is a feeling of overall gloom. You may suspect that a person is struggling with depression if there appears to be an air of sadness about them. People who have worked with depressed people say they can look at most people and sense they have depression without ever talking to them.
2. When a person is depressed, he or she loses perspective.
Depression is like a set of camera filters that color all of life in dark shadows and take away the warmth of life. These filters apply to God, ourselves and all of life. Although there may be some really bad circumstances, depression makes it seem even worse.
3. The depressed person experiences changes in physical activity.
Usually this change is seen in sleeping, eating and sex. A person may eat too much or too little, have sleep disturbances or sleep too much, lose interest in a normal sex life or lose all inhibitions related to sex. Of course, if the person who has the brain injury is depressed, you can see how these indicators of depression add to problems that may already be present because of cognitive deficits. A person may also begin to feel physical aches and pains.
4. There is a general loss of self-esteem.
The longer the depression lingers the less and less positive a person feels about himself and begins to question his value. Self-confidence is very low. Again, a person who has sustained a brain injury may already deal with low self-confidence because of lost cognitive and reasoning abilities, loss of a job, loss of friends, etc. Depression may add to what is already happening in the person’s life.
5. There tends to be a withdrawal from others.
The depressed person cancels activities, fails to return phone calls, and seeks to avoid situations where he or she is around others. The person may not be very pleasant to be around, which is true, but that makes him or her fearful of rejection. One of the biggest issues we see in our association is social isolation of both persons with brain injury and their caregivers. Support groups are one means of connecting with others who understand what is happening in your life because of the brain injury. I might add, however, that one needs to connect to the community outside of the support group through a church, fitness group, civic groups, recreational activity, etc.
6. There is a desire to escape from problems. Maybe even from life itself.
Thoughts of running away or even ending it all may take place. If suicidal thoughts are present one needs to seek out professional help immediately.
7. A depressed person is oversensitive to what others say or do.
He or she may misinterpret comments and actions of others in a negative way. The person may become irritable because of these misperceptions. Often the person cries easily over comments or actions that were not intended to be negative. Of course, this compounds the problems that a person with brain injury may already be having because of problems with subtle social cues and good decision making skills.
8. There is a change in activity and level of thinking.
This may include an inability to concentrate or make sound decisions. You may hear that a person has suddenly quit a very good job and they can’t give you a good reason. For those who are familiar with the consequences of brain injury, you can see how this aspect of depression can compound already existing problems.
9. The person has difficulty handling most of his or her feelings, especially anger.
A person may be angry at themselves, which in turn leads them to be angry at others. It is hard to have a good attitude towards others when you are really angry at yourself.
10. Guilt is usually present at a time of depression.
The basis for guilt may be real or imagined. The person may feel guilty because they are making other people unhappy through their depression.
11. Often, depression leads to a state of dependence upon other people.
This reinforces the feelings of helplessness; then the person becomes angry at his own helplessness, which deepens the depression.
It is important to remember that once a person starts becoming depressed, he or she usually behaves in a way that reinforces the depression.
IV. Different Types of Depression
1. Acute depression
Comes suddenly, symptoms are intense, last a brief period. Person recovers. Usually happens when a person is in the midst of a very difficult crisis.
2. Chronic depression
These are the kind that may affect people for years. Very difficult to treat, may require medication, probably some brain chemical imbalance.
3. Reactive Depression.
Loss of a job, a friend, an opportunity you thought was coming your way. It can be a response to something positive, like getting a new job, or marriage, or a new home. This reaction makes sense because there has been a change and we are trying to deal with that change.
4. Grieving depression.
A normal and healthy response to the death of a loved one. In is the depression we need in order to resolve the loss and move on with life.
Three important questions:
(1) what is the cause of the depression
(2) How is the person functioning
(3) Have they had a physical exam lately
V. A Quick Glance at Possible Causes
1. inadequate food and rest
2. insufficient rest
3. improper treatment of the body
4. a glandular imbalance
6. repressed anger
7. Violating one’s value system
8. Unrealistic expectations
9. Continued negative thinking
Hibbard, M., Uysal, S., Kepler, K. et al. (1998). Axis I psychopathology in individuals with TBI: a retrospective study. Journal of Head Trauma Rehabilitation, 13 (4), 24-39.