Author: Murphy, Enda
Zhang Nan was a 22-year-old man who was referred to me at my clinic in Shen Yang City, Liaoning Province. He was a college student who lived with his parents and grandparents in their 3 bedroom apartment. Zhang reported that he was finding college increasingly difficult to cope with. Last year he had failed one of his major exams and had to repeat it. He said that this had really affected his confidence and he had started experiencing increasing levels of anxiety and difficulty in applying himself to his studies. This was being exacerbated by increasing tension with his parents over his poor college performance. Collateral information from his parents confirmed this. They described Zhang as having been an excellent student and son. He had graduated first in his class in high school, but they complained that he had become increasingly ‘lazy’ since starting college.
When assessing cases of major depression, it is important to understand how environmental, cognitive and biochemical factors interact with each other in causing the problem. In order to be able develop a holistic plan of treatment, assessment should be performed under three headings:
1) Biochemical/clinical assessment (How we work)
2) Cognitive assessment (How we think)
3) Lifestyle/social assessment (How we live)
An easy way to differentiate between normal variations in our emotions and major depression is to use the analogy that ‘Feelings are to weather as mood is to climate.’
It is perfectly normal for young adults who are in college to want to do well. It is common though to find some students drive themselves too hard. This works for a while when they start college but as they demand that they must never fail, they can develop structural and functional vulnerability in their brain that can unravel when the encounter substantial stressors like failing an exam. Their emotional brain can then go into a cycle of extreme negative thinking. This, combined with changes in their biochemical make up, can cause actual physical changes in the brain, leading to all the classical features of major depression. Or in other words when Zhang encountered the strain of not being able to achieve his demand of always getting 100%, his brain started to experience ‘climatic’ change in his mood. When I examined him he had all the symptoms of depression which are low mood, anxiety, fatigue, poor concentration, poor memory, sleep difficulties, loss of libido and drive, loss of appetite with occasional binge eating, negative thinking, loss of self esteem, and loss of enjoyment in life.
Zhang admitted that he had vague thoughts of harming himself but as he had no intent or plan, this was not clinically significant at the time.
Zhang, like a lot of students who get major depression, was experiencing a particular negative thinking cycle which had to be addressed. Like a lot of students,
Zhang believed that in order to be a good student he must get A+ in every exam. Unfortunately the more he tried to get everything perfect, the more he could see himself getting things wrong. This created a cycle of negative thinking and a behaviour pattern that the harder he tried to do things ‘right’ the more he could see himself getting things wrong. Zhang had, quite simply, never learned how to fail at something. This unhealthy thinking/behaviour cycle was being reinforced in his relationship with his parents who had become very critical of Zhang and misinterpreted his symptoms of major depression as him being ‘lazy’.
Like a lot of students, Zhang had been neglecting his own needs and diet. He was not eating healthily and due to exhaustion and the pressure of his studies, he was getting virtually no aerobic exercise.
Empathy is one of the most important tools in the treatment of depression. A simple explanation of what was happening, why it was happening and how we were going to treat it, was given to Zhang and his family. This had the effect of ‘normalising’ what was going on and relieving a lot of their stress and uncertainty. As Zhang had all the classical symptoms of depression he was started on an SSRI antidepressant. This had the effect of elevating his mood to a point whereby he could engage with therapy.
A simple exercise regime of 20 minutes fast walk twice a day was introduced.
Diet was improved with the inclusion of fish containing a high content of Omega 3 fatty acids. Zhang was also given vitamin B complex to assist his immune system.
SSRI antidepressants usually take 14 to 21 days to start working. As his mood improved, low intensity Cognitive Behaviour
Therapy (CBT) was introduced to help Zhang correct his unhealthy/unhelpful thinking and behaviour. His family were also seen for some low intensity CBT to help them look
and improve their relationship with Zhang. This had the effect of changing his parents’ attitude from one of constant criticism to one of understanding and support.
As Zhang’s condition improved, his therapy was gradually reduced. His mental and physical well being increased along with his confidence and performance in college. His progress was monitored and lessons learned during therapy sessions reinforced over the following few months.
Extensive research into the use of antidepressants suggests that treatment should be continued for between 6 and 9 months after mood stabilisation has been achieved. This has the effect of reducing the chances of relapse.
Zhang and his family were reviewed one year after starting treatment. Zhang and his parents felt that all the social and environmental issues that had contributed to his depression had resolved. As it was now over 9 months since his mood had stabilised, withdrawal of the SSRI was discussed. Zhang and his parents were happy with this. His Antidepressant was discontinued gradually over the subsequent few weeks. Zhang has since completed his undergraduate degree and is busily and more importantly, happily studying for his Master’s degree.
Document Type: Research Article