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Depression

Depression (major depressive disorder) is a common and serious medical illness that negatively affects how you feel, the way you think and how you act. Fortunately, it is also treatable. Depression causes feelings of sadness and/or a loss of interest in activities once enjoyed. It can lead to a variety of emotional and physical problems and can decrease a person’s ability to function at work and at home.

Depression symptoms can vary from mild to severe and can include:

  • Feeling sad or having a depressed mood
  • Loss of interest or pleasure in activities once enjoyed
  • Changes in appetite — weight loss or gain unrelated to dieting
  • Trouble sleeping or sleeping too much
  • Loss of energy or increased fatigue
  • Increase in purposeless physical activity (e.g., hand-wringing or pacing) or slowed movements and speech (actions observable by others)
  • Feeling worthless or guilty
  • Difficulty thinking, concentrating or making decisions
  • Thoughts of death or suicide

Symptoms must last at least two weeks for a diagnosis of depression.

Also, medical conditions (e.g., chronic physical illnesses, thyroid problems, a brain tumor or vitamin deficiency) can mimic or cause symptoms of depression so it is important to rule out general medical causes.

Most recent survey showed 17% lifetime prevalence of depression which is highest of any psychiatric disorder (range 5-17%). Depression can occur at any time, but is more prevalent in middle aged women. Women are more likely than men to experience depression. Some studies show that one-third of women will experience a major depressive episode in their lifetime. Recent data suggests that incidence of depression is increasing among people younger than 20 years of age.

Etiology of Depression

Etiology is multi factorial and several factors play a role in depression:

  • Biochemistry: Differences in neuro-chemicals like serotonin, norepinephrine and dopamine in the brain may contribute to symptoms of depression.
  • Genetics: Depression can run in families. For example, if one identical twin has depression, the other has a 70-90 percent chance of having the illness sometime in life.
  • Alteration in hormone regulation
  • Negative view about self, future and environment.
  • Personality: People with low self-esteem, who are easily overwhelmed by stress, or who are generally pessimistic appear to be more likely to experience depression.
  • Environmental factors: Continuous exposure to violence, neglect, abuse or poverty may make some people more vulnerable to depression.

Depression Vs Grief/Bereavement

The events like death of a loved one, loss of a job or the ending of a relationship are difficult experiences in person’s life. It is normal for feelings of sadness or grief to develop in response to such situations. Those experiencing loss often might describe themselves as being “depressed.”

But being sad is not the same as having depression. The grieving process is natural and unique to each individual and shares some of the same features of depression. Both grief and depression may involve intense sadness and withdrawal from usual activities. They are also different in important ways:

  • In grief, painful feelings are often intermixed with positive memories of the deceased. In major depression, mood and/or interest (pleasure) are decreased for most of two weeks.
  • In grief, self-esteem is usually maintained. In major depression, feelings of worthlessness and self-loathing are common.
  • For some people, the death of a loved one can bring on major depression. Losing a job or being a victim of a physical assault or a major disaster can lead to depression for some people. When grief and depression co-exist, the grief is more severe and lasts longer than grief without depression. Despite some overlap between grief and depression, they are different. Distinguishing between them can help people get the help, support or treatment they need.

Course and prognosis

Untreated depressive episode last for 6-13 months; most treated episodes last for about 3 months. Withdrawal of treatment before 3 months increases the chances of relapse. About 25% of the depression patients have recurrence of illness within 6 months of discharge from the hospital.

Treatment

Depression is treatable illness. Between 80 -90 percent of people with depression eventually respond well to treatment. Almost all patients gain some relief from their symptoms.

A thorough diagnostic evaluation including history, physical examination and mental status examination should be done. In some cases, a blood tests might be done to rule out medical condition like a hypothyroidism. The evaluation is to identify specific symptoms, medical and family history, cultural factors and environmental factors to arrive at a diagnosis and plan a treatment.

Medication: 

There are various classes of anti-depressant drugs. The selection is usually done based on symptom profile & demographic profile of the patient and side effect profile of the drug.

Anti-depressant drugs usually show significant therapeutic effects after 3-4 weeks of medication intake.

Anti-depressant treatment should be continued for at least 6 months or for the length of previous episode, whichever is greater. Prophylactic treatment helps in reducing the number and severity of recurrences. 

Antidepressants may produce some improvement within the first week or two of use. If a patient feels little or no improvement after several weeks, his or her psychiatrist can alter the dose of the medication or add or substitute another antidepressant. In some situations other psychotropic medications may be helpful. It is important to let your doctor know if a medication does not work or if you experience side effects.

Psychotherapy

Psychotherapy usually advised alone for treatment of mild depression. For moderate to severe depression, psychotherapy is often used in along with antidepressant medications.

Cognitive behavioral therapy (CBT) has been found to be effective in treating depression. CBT is a form of therapy focused on the present and problem solving. CBT helps a person to recognize distorted thinking (cognitive distortions) and then change behaviors and thinking.

Psychotherapy may involve only the individual, but it can include others. For example, family or couples therapy can help address issues within these close relationships. Group therapy involves people with similar illnesses.

Depending on the severity of the depression, treatment can take a few weeks or much longer. In many cases, significant improvement can be made in 10 to 15 sessions.

Rational Emotive Behavioral Therapy (REBT) also prescribed for some patients. It focuses on modifying the irrational beliefs and help individual to think rationally.

Electroconvulsive Therapy (ECT) is a medical treatment most commonly used for patients with severe major depression with suicidal ideas/attempts it is also given to patients who do not respond to medications. It involves a brief electrical stimulation of the brain while the patient is under anesthesia. A patient typically receives ECT two to three times a week for a total of 6 to 12 treatments. It is usually managed by a team of trained medical professionals including a psychiatrist, an anesthesiologist and a nurse or physician assistant.

For some patients hospital admission and close observation is needed.

Lifestyle modification and self help

Many things can be done to reduce the symptoms of depression. For many people, regular exercise helps create positive feeling and improve mood. Getting enough quality sleep on a regular basis, eating a healthy diet and avoiding alcohol or other substances of abuse can also help reduce symptoms of depression. Cherishing hobbies, sharing feelings with someone, doing things that give pleasure, self relaxation, meditation, etc can help reduce symptoms of depression to some extent.

Depression can be of following types