Depression

General Medical Consideration

Presented by

Dr. Pawan S. Chandak BHMS (India)

Email: pavanchandak498@gmail.com

Clinical depression (also called major-depressive disorder, or unipolar depression when compared to bipolar disorder) is a common mood disorder in psychology and psychiatry, in which a person's enjoyment of life and ability to function socially and in day to day matters is disrupted by intense sadness, melancholia, numbness, or despair.

There are several subtypes, some of which meet the popular perception of sadness, agitation and disruption of sleeping and eating, and others of which do not disrupt enjoyment of good things but create a highly disruptive cycle of inner paralysis and lethargy.

Clinical depression affects about 7–18% of the population on at least one occasion in their lives, before the age of 40.

General background

Although a low mood or state of dejection that does not affect functioning is often colloquially referred to as depression, clinical depression is a clinical diagnosis and may be different from the everyday meaning of "being depressed." Many people identify the feeling of being clinically depressed as "feeling sad for no reason", or "having no motivation to do anything." A person suffering from depression may feel tired, sad, irritable, lazy, unmotivated, and apathetic. Clinical depression is generally acknowledged to be more serious than normal depressed feelings. It often leads to constant negative thinking and sometimes substance abuse or self-harm. Extreme depression can culminate in its sufferers attempting or completing suicide.

Prevalence

Major Depressive disorder has a lifetime prevalence of 10-25 % for women and 5-12 % for men. For Bipolar disorder lifetime pravalence of 0.4 - 1.6 %. In general Medical Practice the prevalence of depressive disorder ranges from 15-25 %. Major depressive disorder is twice as frequent in women as compared to man and has a mean age of onset of forty years. It occurs more frequently among separated and divorced persons. Individual with a family history of mood disorders, suicidal attempts or acoholism have higher rates of suffering from mood disorders.

Causes of clinical depression

Current theories regarding the risk factors and causes of clinical depression can be broadly classified into two categories, Physiological and Sociopsychological:

Physiological causes

Genetic predisposition

The tendency to develop depression may be inherited: according to the National Institute of Mental Health there is some evidence that depression may run in families, though this familial trend probably includes both biological and environmental factors.

Neurological

Evidence has shown the involvement of neurogenesis in depression, though the role is not exactly known. Recent research has suggested that there may be a link between depression and neurogenesis of the hippocampus. This horseshoe-shaped structure is a center for both mood and memory. Loss of neurons in the hippocampus is found in depression and correlates with impaired memory and dysthymic mood. That is why treatment usually results in an increase of serotonin levels in the brain which would in turn stimulate neurogenesis and therefore increase the total mass of the hippocampus and restores mood and memory, therefore assisting in the fight against the mood disorder.

In about one-third of individuals diagnosed with attention-deficit hyperactivity disorder (ADHD), a developmental neurological disorder, depression is recognized as comorbid. Dysthymia, a form of chronic, low-level depression, is particularly common in adults with undiagnosed ADHD who have encountered years of frustrating ADHD-related problems with education, employment, and interpersonal relationships.

Medical conditions:

Certain illnesses, including cardiovascular disease, hepatitis, mononucleosis, hypothyroidism, and organic brain damage caused by degenerative conditions such as Parkinson disease, Multiple Sclerosis or by traumatic blunt force injury may contribute to depression, as may certain prescription drugs such as hormonal contraception methods and steroids.

Dietary

The increase in depression in industrialized societies has been linked to diet, particularly to reduced levels of omega-3 fatty acids in intensively farmed food and processed foods. It can also be caused by a magnesium deficiency or lower magnesium levels.

Sleep quality

Poor sleep quality co-occurs with major depression. Major depression leads to alterations in the function of the hypothalamus and pituitary causing excessive release of cortisol which can lead to poor sleep quality. Individuals suffering from Major Depression have been found to have an abnormal sleep architecture, often entering REM sleep sooner than usual, along with highly emotionally-charged dreaming. Antidepressant drugs, which often function as REM sleep suppressants, may serve to dampen abnormal REM activity and thus allow for a more restorative sleep to occur.

Seasonal affective disorder

Seasonal affective disorder (SAD) is a type of depressive disorder that occurs in the winter when daylight hours are short. It is believed that the body's production of melatonin, which is produced at higher levels in the dark, plays a major part in the onset of SAD and that many sufferers respond well to bright light therapy, also known as phototherapy.

Postpartum depression

Postpartum depression refers to the intense, sustained, and sometimes disabling depression experienced by women after giving birth. Postpartum depression, which has incidence rate of 10-15%, typically sets in within three months of labor and can last for as long as three months. About two new mothers out of a thousand experience the more serious depressive disorder Postnatal Psychosis which includes hallucinations and/or delusions.

Sociopsychological causes

Psychological factors

Low self-esteem and self-defeating or distorted thinking are connected with depression. It is known that depressed persons who are able to make corrections in their thinking patterns can show improved mood and self-esteem (Cognitive Behavioral Therapy).  Psychological factors related to depression include the complex development of one's personality and how one has learned to cope with external environmental factors such as stress.

Early experiences

Events such as the death of a parent, issues with biological development, school related problems, abandonment or rejection, neglect, chronic illness, and physical, psychological, or sexual abuse can also increase the likelihood of depression later in life. Post-traumatic stress disorder (PTSD) includes depression as one of its major symptoms.

Life experiences

Job loss, poverty, financial difficulties, gambling addiction, eating disorders, long periods of unemployment, the loss of a spouse or other family member, rape, divorce or the end of a committed relationship, involuntary celibacy, inability to have proper sex or premature ejaculation or other traumatic events may trigger depression. Long-term stress at home, work, or school can also be involved.

Clinical Features:

Types

Major clinical depression

Major Depression, or, more properly, Major Depressive Disorder (MDD), is characterized by a severely depressed mood that persists for at least two weeks. Major Depressive Disorder is specified as either "a single episode" or "recurrent", depending on whether periods of depression occur as discrete events or recur within an individual's lifespan. Episodes of major or clinical depression may be further divided into mild, major or severe. If the patient has already had an episode of mania or markedly elevated mood, a diagnosis of bipolar disorder (also called bipolar affective disorder) is usually made instead of MDD; depression without periods of elation or mania is therefore sometimes referred to as unipolar depression because the mood remains at one emotional state ("pole"). The diagnosis also usually excludes cases where the symptoms are a normal result of bereavement. Diagnosticians recognize several possible subtypes of Major Depressive Disorder. ICD-10 does not specify a melancholic subtype, but does distinguish by presence or absence of psychosis.

Other categories of depression

Overlapping psychological features

Anxiety

The different types of depression and anxiety are classified separately by the DSM-IV-TR, with the exception of hypomania, which is included in the bipolar disorder category. Despite the different categories, depression and anxiety can indeed be co-occurring (occurring together), independently (without mood congruence), or comorbid (occurring together, with overlapping symptoms, and with mood congruence). In an effort to bridge the gap between the DSM-IV-TR categories and what clinicians actually encounter, experts such as Herman Van Praag of Maastricht University have proposed ideas such as anxiety/aggression-driven depression. This idea refers to an anxiety/depression spectrum for these two disorders, which differs from the mainstream perspective of discrete diagnostic categories.

Although there is no specific diagnostic category for the comorbidity of depression and anxiety in the DSM or ICD, the National Comorbidity Survey (US) reports that 58 percent of those with major depression also suffer from lifetime anxiety. Supporting this finding, two widely accepted clinical colloquialisms include

It is also clear that even mild anxiety symptoms can have a major impact on the course of a depressive illness, and the commingling of any anxiety symptoms with the primary depression is important to consider.

Hypomania

Hypomania, as the name suggests, is a state of mind or behavior that is "below" (hypo) mania. In other words, a person in a hypomanic state often displays behavior that has all the hallmarks of a full-blown mania (e.g., marked elevation of mood that is characterized by euphoria, overactivity, disinhibition, impulsivity, a decreased need for sleep, hypersexuality), but these symptoms, though disruptive and seemingly out of character, are not so pronounced as to be considered a diagnosably manic episode. In a psychiatric context, it is important to identify the possible presence and characteristics of manic and hypomanic episodes, since these may lead to a diagnosis of bipolar disorder, which is medically treated differently from depression.

Another important point is that hypomania is a diagnostic category that includes both anxiety and depression. It often presents as a state of anxiety that occurs in the context of a clinical depression. Patients in a hypomanic state often describe a sense of extreme generalized or specific anxiety, recurring panic attacks, night terrors, guilt, and agency (as it pertains to codependence and counterdependence). All of this happens while they are in a state of retarded or somnolent depression. This is the type of depression in which a person is lethargic and unable to move through life. The terms retarded and somnolent are shorthand for states of depression that include lethargy, hypersomnia, a lack of motivation, a collapse of ADLs (activities of daily living), and social withdrawal. This is similar to the shorthand used to describe an "agitated" or "apathetic" depression.

Diagnosis

It is hard for people who have not experienced clinical depression, either personally or by regular exposure to people suffering it, to understand its emotional impact and severity, interpreting it instead as being similar to "having the blues" or "feeling down". As the list of symptoms below indicates, clinical depression is a serious, potentially lethal systemic disorder characterized by the psychiatric profession as interlocking physical, affective, and cognitive symptoms that have consequences for function and survival well beyond sad or painful feelings.

DSM-IV-TR criteria

According to the DSM-IV-TR criteria for diagnosing a major depressive episode five (or more) of the following symptoms must be present for a period of at least two weeks and represent a change from previous functioning; at least one of the symptoms is either depressed mood or loss of interest or pleasure, that is, one of the first two symptoms listed below:


Mnemonics commonly used to remember the DSM-IV criteria are SIGECAPS (sleep, interest [anhedonia], guilt, energy, concentration, appetite, psychomotor, suicidality), DEAD SWAMP (depressed mood, energy, anhedonia, death [thoughts of], sleep, worthlessness/guilt, appetite, mentation, psychomotor) and DIG SPACES (depressed mood, interest [lack of], guilt/worthlessness, suicidal ideation, psychomotor agitation/retardation, anorexia/weight loss, concentration difficulties, energy loss/fatigue, sleep disturbances).

Patient Health Questionnaire 2

The Patient Health Questionnaire (PHQ2) is a faster, two question questionnaire that may be as sensitive as the DSM-IV: "During the past month, have you often been bothered by:"

  1. "little interest or pleasure in doing things?"
  2. "feeling down, depressed, or hopeless?"

If either question is positive, then the SALSA questionnaire should be used for more certainty. A positive test is one of the above answers positive and two of the answers below positive:

  1. Sleep disturbance nearly every day for the last 2 weeks?
  2. Have you experienced little interest or pleasure in doing things nearly every day for the last 2 weeks (Anhedonia)?
  3. Have you experienced Low Self esteem nearly every day for the last 2 weeks?
  4. Have you experienced decreased Appetite nearly every day for the last 2 weeks?"

Other symptoms

Other symptoms often reported but not usually taken into account in diagnosis include:

An additional indicator could be the excessive use of drugs or alcohol. Depressed adolescents are at particular risk of further destructive behaviours, such as eating disorders and self-harm.

A recent study in Journal of Nervous and Mental Disease showed that alternative symptoms of depression including diminished drive, hopelessness and helplessness, lack of reactivity, anger, psychic and somatic anxiety can be as effective as current DSM-IV criteria in diagnosis. According to this study, diminished drive has a higher diagnostic criteria than all others except for depressed mood with sensitivity of 88.2 of specificity of 69.9 . This is only one study though, and has yet to be repeated.

Depression in children is not as obvious as it is in adults. Children may show symptoms such as:

Differential Diagnosis:

Without careful assessment, delirium can easily be confused with depression and a number of other psychiatric disorders because many of the signs and symptoms are conditions present in depression, as well as other mental illnesses including dementia and psychosis.

Treatment

Treatment of depression varies broadly among individuals. The level, type, and methods of intervention vary dramatically. There are two primary modes of treatment that are typically used in conjunction; medication and psychotherapy. A significant number of recent studies have indicated that changes in lifestyle such as regular exercise and dietary supplements have beneficial effects.

Treatment-resistant depression warrants a full assessment, which may lead to the introduction of psychotherapy, a focus on lifestyle change, an increase of medication, or a change in medication.

In emergencies, hospitalization is an intervention employed to keep at-risk individuals safe until they cease to be a danger to themselves or others. An alternative treatment program is partial hospitalization, in which the patient sleeps at home but spends most of the day in a psychiatric hospital setting. This intensive treatment usually involves group therapy, individual therapy, medication management, and is used often in the case of children and adolescents.

Dietary supplements

5-HTP supplements are claimed to provide more raw material to the body's natural serotonin production process. T

S-adenosyl methionine (SAM-e) is a derivative of the amino acid methionine that is found throughout the human body, where it acts as a methyl donor and participates in other biochemical reactions.

Omega-3 fatty acids (found naturally in oily fish, flax seeds, hemp seeds, walnuts, and canola oil) have also been found to be effective when used as a dietary supplement (although only fish-based omega-3 fatty acids have shown antidepressant efficacy.)

Dehydroepiandrosterone (DHEA), available as a supplement in the U.S., has been shown to be effective in small trials.

Magnesium supplementation has gathered some attention as a possible treatment for depression.

Ginkgo Biloba Effective natural antidepressant said to stabilise cell membranes, inhibiting lipid breakdown and aiding cell use of oxygen and glucose - so subsequently a mental and vascular stimulant that improves neurotransmitter production. Also popular for treating mental concentration (such as for Alzheimer's and stroke patients).

Siberian Ginseng [Eleutherococcus senticosus] Although not a true panax ginseng it is claimed by some to be a mood enhancement supplement against stress.

Zinc has had an antidepressant effect in an experiment.

Biotin: a deficiency has caused a severe depression.

B vitamins: Symptoms of a deficiency in vitamins such as vitamin B6, B12 and others can include depression and other psychiatric disorders.

Chromium: Evidence has emerged that supplementing with high doses of chromium (ie: in doses of several hundred to 100 mg) exerts antidepressant effects.

Rhodiola Rosea:  It has been shown to help alleviate depression and fatigue also elevate extracellular levels of monoamines and beta-endorphins.

Psychotherapy

In psychotherapy, or counseling, one receives assistance in understanding and resolving habits or problems that may be contributing to or the cause of the depression. This may be done individually or with a group and is conducted by mental health professionals such as psychiatrists, psychologists, clinical social workers, or psychiatric nurses.

Effective psychotherapy may result in different habitual thinking and action which leads to a lower relapse rate than antidepressant drugs alone. Medication, however, may yield quicker results and be strongly indicated in a crisis. Medication and psychotherapy are generally complementary, and both may be used at the same time.

It is important to ask about potential therapists' training and approach; a very close bond often forms between practitioner and client, and it is important that the client feel understood by the clinician. Moreover, some approaches have been convincingly demonstrated to be much more effective in treating depression.

Counselors can help a person make changes in thinking patterns, deal with relationship problems, detect and deal with relapses, and understand the factors that contribute to depression.

There are many counseling approaches, but all are aimed at improving one's personal and interpersonal functioning. Cognitive behavioral therapy (CBT) has been demonstrated in carefully controlled studies to be among the foremost of the recent wave of methods which achieve more rapid and lasting results than traditional "talk therapy" analysis. Cognitive therapy, often combined with behavioral therapy, focuses on how people think about themselves and their relationships. It helps depressed people learn to replace negative depressive thoughts with realistic ones, as well as develop more effective coping behaviors and skills. Therapy can be used to help a person develop or improve interpersonal skills in order to allow him or her to communicate more effectively and reduce stress. Interpersonal psychotherapy focuses on the social and interpersonal triggers that cause their depression. Narrative therapy gives attention to each person's "dominant story" by means of therapeutic conversations, which also may involve exploring unhelpful ideas and how they came to prominence. Possible social and cultural influences may be explored if the client deems it helpful. Behavioral therapy is based on the assumption that behaviors are learned. This type of therapy attempts to teach people more healthful types of behaviors. Supportive therapy encourages people to discuss their problems and provides them with emotional support. The focus is on sharing information, ideas, and strategies for coping with daily life. Family therapy helps people live together more harmoniously and undo patterns of destructive behavior.

 

Transcranial magnetic stimulation

Vagus nerve stimulation

Other methods of treatment

Acupuncture

In studies, acupuncture appears to be helpful in reducing depression.

Light therapy

Bright light (both sunlight and artificial light) is shown to be effective in seasonal affective disorder, and sometimes may be effective in other types of depression, especially atypical depression or depression with "seasonal phenotype" (overeating, oversleeping, weight gain, apathy).

Exercise

It is widely believed that physical activity and exercise help depressed patients and promote quicker and better relief from depression. They are also thought to help antidepressants and psychotherapy work better and faster. It can be difficult to find the motivation to exercise if the depression is severe, but sufferers should be encouraged to take part in some form of regularly scheduled physical activity. A workout need not be strenuous; many find walking, for example, to be of great help. Exercise produces higher levels of chemicals in the brain, notably dopamine, serotonin, and norepinephrine. In general this leads to improvements in mood, which is effective in countering depression.

Meditation

Meditation is increasingly seen as a useful treatment for some cases of depression. The current professional opinion on meditation is that it represents at least a complementary method of treating depression, a view that has been endorsed by the Mayo Clinic. Since the late 1990s, much research has been carried out to determine how meditation affects the brain . Although the effects on the mind are complex, they are often quite positive, encouraging a calm, reflective, and rational state of mind that can be of great help against depression.

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