Knowing Depression

According to WHO, Globally, an estimated 350 million people of all ages suffer from depression. It is the leading cause of disability worldwide and is a major contributor to the overall global burden of disease. It has been identified that Unipolar Depression is the 4th cause of DALY (Disability – Adjusted Life Year) in all ages and 2nd cause in the age group of 15 – 44 years. Unipolar Depression is also the 1st cause of YLD (Years of Life Lived with Disability) in all ages. The comparison was with all medical disorders, and not only psychiatric disorders. This shows how widely it affects us. But sadly, most of the cases just go unattended, due to lack of knowledge.

Definition

“Clinical Depression is a state of feeling sad and depressed for weeks or months on end — not just a passing blue mood of a day or two.” It isn’t the same as depression caused by a loss, such as the death of a loved one, or a medical condition, such as a thyroid disorder.

Diagnostic Criteria

Among the criteria for a major depressive disorder, at least five of the nine symptoms below should be present for two weeks or more, most of the time almost every day, and this is a change from his/her prior level of functioning. One of the symptoms must be either (a) depressed mood, or (b) loss of interest.

1. Depressed mood most of the day. for children and adolescents, this may be irritable mood.
2. Diminished interest or pleasure in all or most activities.
3. Significant unintentional weight loss or gain.
4. insomnia or sleeping too much or waking up 2 hours early than usual time.
5. Agitation or psycho motor retardation noticed by others.
6. Fatigue or less of energy.
7. feelings of worthlessness or excessive guilt.
8. Diminished ability to think or concentrate, or indecisiveness.
9. Recurrent thoughts of death.

Signs And Symptoms

Psychological symptoms include:

• continuous low mood or sadness
• feeling hopeless and helpless
• having low self-esteem 
• feeling tearful
• feeling guilt-ridden
• feeling irritable and intolerant of others 
• having no motivation or interest in things
• finding it difficult to make decisions
• not getting any enjoyment out of life
• feeling anxious or worried 
• having suicidal thoughts or thoughts of harming yourself

Physical symptoms include:

• moving or speaking more slowly than usual 
• change in appetite or weight (usually decreased, but sometimes increased) 
• constipation 
• unexplained aches and pains
• lack of energy or lack of interest in sex (loss of libido)
• changes in menstrual cycle
• disturbed sleep (for example, finding it hard to fall asleep at night or waking up very early in the morning)

Social symptoms include:

• not doing well at work
• taking part in fewer social activities and avoiding contact with friends
• neglecting your hobbies and interests
• having difficulties in your home and family life

Suicidal Risk

Suicidal risk is much more in the presence of the following factors :

• Presence of marked hopelessness
• Male; age > 40 years; Unmarried, divorced / widowed
• Written / verbal communication of suicidal intent and/or plan
• Early stages of depression
• Recovering from depression (at the peak of depression, the patient is usually either too depressed or too retarded to commit suicide)
• Period of 3 months from recovery

Latest Classification Of Depression (According to DSM-5)

Disruptive Mood Dysregulation Disorder:

Children with severe and recurrent temper outbursts that are grossly out of proportion in intensity or duration to the situation. This occurs frequently (3 or more times per week). And also interfere with their ability to function at home, in school, or with their friends.

Major Depressive Disorder, Single and Recurrent Episodes :

It is also known as unipolar depression. The three types of depressive episodes are single, recurrent, and seasonally patterned

• Single – Single episode depression means that a person experiences finite depression, according to the criteria for diagnosis, but does not suffer from it again.
• Recurrent depressive disorder – this disorder involves repeated (at least 2 episodes) depressive episodes with at least two months in between in which no major depressive episode was present.

An individual with a mild depressive episode will have some difficulty in continuing with ordinary work and social activities, but will probably not cease to function completely. During a severe depressive episode, it is very unlikely that the sufferer will be able to continue with social, work, or domestic activities, except to a very limited extent.

• Seasonal Affective Disorder (SAD) – Seasonal affective disorder which starts same time, every year. Usually, symptoms start in the fall and continue into the winter months, sapping their energy and making them feel moody.

Persistent Depressive Disorder (Dysthymia) :

Persistent depressive symptoms last for more than 2 years (One year in children and adolescents) but are not severe enough to be labeled as even hypomanic or mild depressive episodes.

People who suffer from this may be described as having a gloomy personality, constantly complaining, or incapable of having fun. It may significantly interfere with their relationships, school, work, and daily activities.

Premenstrual Dysphoric Disorder :

Premenstrual Dysphoric Disorder (PMDD) is a more severe form of a premenstrual syndrome characterized by significant premenstrual mood disturbance, often with prominent mood reactivity and irritability. Symptoms of PMDD can emerge 1-2 weeks preceding menses and typically resolve with the onset of menses. By definition, this mood disturbance results in marked social or occupational impairment, with its most prominent effects on interpersonal functioning.

In PMDD, however, at least one of these emotional and behavioral symptoms stands out:

• Sadness or hopelessness
• Anxiety or tension
• Extreme moodiness
• Marked irritability or anger

Postpartum Depression:

Postpartum depression is moderate to severe depression in a woman after she has given birth. It may occur soon after delivery or up to a year later. Most of the time, it occurs within the first 3 months after delivery.

Mothers experience feelings of extreme sadness, anxiety, and exhaustion that may make it difficult for them to complete daily care activities for themselves or for others.

Substance/Medication-Induced Depressive Disorder:

Depression may be caused or precipitated by the use or abuse of substances such as drugs, alcohol, medications, or exposure to toxins.

Nearly 30% of people with substance abuse problems also have major or clinical depression.

The essential feature of a drug-induced mood disorder is the onset of symptoms in the context of drug use, intoxication, or withdrawal.

Criteria for Diagnosis of Substance-Induced Mood Disorders –

• A prominent and persistent disturbance in mood predominates, characterised by (a) a depressed mood or markedly diminished interest or pleasure in activities, or (b) an elevated, expansive, or irritable mood.
• there is evidence from the history, physical examination, or laboratory findings that the symptoms developed during or within a month after substance intoxication or withdrawal, or medication use, is etiologically related to the mood disturbance.
• The disturbance is not better explained by a mood disorder.
• The disturbance did not occur exclusively during delirium
• The symptoms cause clinically significant distress or impairment.

Depressive Disorder Due to Another Medical Condition

Depressive disorders due to Another Medical Conditions, are those which are not the result of some mental disorder; they are, instead, a consequence of medical conditions that are not always linked to depression

Depression can stem from a fairly broad spectrum of medical conditions, from brain injury to Huntington’s disease, hypothyroidism, Cushing’s disease, Addison’s disease, diabetes, cancer, heart disease, and Parkinson’s disease, arthritis, kidney disease, HIV/AIDS, lupus, multiple sclerosis, etc.

Bipolar

Bipolar is different from depression, but it is included in this list because someone with bipolar disorder experiences episodes of extremely low moods that meet the criteria for major depression

Bipolar disorder, also known as manic-depressive illness, is a brain disorder that causes unusual shifts in mood, energy, activity levels, and the ability to carry out day-to-day tasks.

These moods range from periods of extremely “up,” elated, and energized behavior (known as manic episodes) to very sad, “down,” or hopeless periods (known as depressive episodes). Less severe manic periods are known as hypomanic episodes.

During a manic episode, a person might impulsively quit a job, charge up huge amounts on credit cards, or feel rested after sleeping two hours. During a depressive episode, the same person might be too tired to get out of bed, and full of self-loathing and hopelessness over being unemployed and in debt.

Common signs and symptoms of mania include –

• Feeling unusually ‘high; and optimistic OR extremely irritable
• Unrealistic, grandiose beliefs about one’s abilities or powers
• Sleeping very little, but feeling extremely energetic
• Talking so rapidly that others can’t keep up
• Racing thoughts; jumping quickly from one idea to the next
• Highly distractible, unable to concentrate
• Impaired judgement and impulsiveness
• Acting recklessly without thinking about the consequences
• Delusion and hallucination (in severe cases)

Common symptoms of bipolar depression include –

• Feeling hopeless, sad, or empty
• Irritability
• Inability to experience pleasure
• Fatigue or loss of energy
• Physical and mental sluggishness
• Appetite or weight changes
• Sleep problems
• Concentration and memory problems
• Feelings of worthlessness or guilt
• Thoughts of death or suicide

Causes –

• Genetic – it has been observed that genetic factors are very important in making an individual vulnerable to mood disorders, particularly so in bipolar mood disorders. However environmental factors are also probably important.
• Biochemical – abnormality in the monoamines catecholamine (norepinephrine and dopamine) and serotonin] system in the central nervous system of our brain at one or more sites.
• Other medical conditions like hypothyroidism, Cushing’s disease, Addison’s disease.
• Major events –  physical, sexual, or emotional abuse, Sadness or grief from the death or loss of a loved one, moving, losing a job or income, getting divorced, or retiring. Even good events such as starting a new job, graduating, or getting married can lead to depression.
• Cognitive and behavioural Theories – include depressive negative cognition (cognitive theory), learned helplessness (animal model), and anger directed inwards. These concepts are useful in the psychological treatment of mild to moderate depression.

Management –

1. Medications –
   • Modern medicines – antidepressants, antipsychotics and other mood stabilizers are used. At times stereotactic subcaudate tractotomy or stereotactic limbic leucotomy are also done.
   • Homoeopathy – Homoeopathy is one of the safest and effective mode of treatment for all types of Depressions, esp. in the early stages. Homeopathy can take care of various symptoms of depression.

In the treatment, the cause is first found out. Homeopathy is one of the most popular holistic systems of medicine. The selection of remedy is based upon the theory of individualization and symptoms similarity by using a holistic approach. This is the only way through which a state of complete health can be regained by removing all the signs and symptoms from which the patient is suffering. The aim of homeopathy is not only to treat depression but to address its underlying cause and individual susceptibility. As far as therapeutic medication is concerned, several medicines are available for depression treatment that can be selected on the basis of cause, condition, sensation, and modalities of the complaints.

2. Psychosocial Treatment –
   • Hypnotherapy – in mild to moderate cases along with appropriate medications, this therapy helps the person to correct depressive negative thought patterns & emotions and replace them with new cognitive and behavioural responses, recognise his interpersonal stressors, etc. However Hypnotherapy is less effective in cases of sever Bipolar and Schizophrenia
   • Psychoanalytic Psychotherapy – aim at changing the personality itself rather than just ameliorating the symptoms
   • Behaviour Therapy – modalities like social skills training, self-control therapy, problem solving techniques, assertiveness training, activity scheduling and decision making techniques are used.
   • Group Therapy – very useful method for psychoeducation
   • Family And Marital Therapy – helps by educating the family about the nature of the illness and usefulness of the medications. And also to decrease the intrafamilial and interpersonal difficulties, and to reduce or modify stressors, which may help in a faster and more complete recovery.