1. Introduction
Anxiety, depression, and bipolar disorders are the typical emotional disorders. The symptoms of these affective disorders are subjective feeling, and only those who have experienced these can understand the agony. Out of these, depression is estimated to affect 350 million people and is the leading cause of disability globally. Not only has it affected persons with depression but their families too. Despite known effective treatments, many do not seek help and remain in denial mode. Untreated and severe depression may lead to attempts and feelings of stigmatization or suicidal ideation.
Depression is more common in women than men. Nearly every thirteenth person in India runs at the risk of developing an episode of depression during his lifetime. As per WHO, the average age of depression in India is 31.9 years.
2. Types of depression
There are many variations of depression with the most general distinction being depression in people who have or do not have a history of manic episodes.
The former is categorized as a unipolar depressive disorder and includes major depression alone. It can vary from mild, moderate to severe. The other type having a combination of both depression and mania is termed bipolar mood disorders (also known as manic-depressive illness). It is not as common as major depression. It is characterized by cycling fluctuation of mood swings from mania (feeling high) to depression (feeling low).
There are many other subcategories of major depression and they include:
Major depression may be seen in association with psychosis. People with psychosis may hear "voices" or see things which others cannot hear or see (hallucinations) or they may have strong false beliefs or illogical ideas like possessed by evil (delusions). This form is known as psychotic depression.
Majority of new mother suffers from postpartum blues where the feeling of being overwhelmed are mixed with low and having difficulty in sleeping. It usually resolves in a month. Postpartum depression is the more serious manifestation of this where it rapidly expands to other symptoms that typically include sadness or anxiousness through the day that often worsens in the evening; crying spells; low self-esteem; lethargy and sleeplessness. It affects one in every five new mothers in India.
Seasonal affective disorder, which is characterized by the onset of depression during the winter months, when there is less natural sunlight. The depression generally lifts during spring and summer. Commonly it is seen in temperate climates with features like carbohydrate craving, excessive sleepiness and excessive eating.
3. Causes
Depression is multifactorial. A family history increases the risks and genetic factors are already established. It usually is a manifestation of psychosocial stresses like major events, sudden death, divorce, loss of job, serious illness or social isolation. Although sadness and grief are normal responses to loss, depression is not. Grief is usually accompanied by intact self-esteem, whereas depression is marked by a sense of guilt and worthlessness. It may also be the final expression of past physical and sexual abuse manifesting at later stage or of drug abuse.
4. Signs and Symptoms
Mood swings from mild sadness to intense feelings of hopelessness. Mood worsening in the morning and associated guilt feeling
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Difficulty in thinking, early morning awakening, difficulty in concentration, lack of self confidence and subjective experience of memory loss
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Joylessness, disruption in social functioning with diminished involvement in work and recreation.
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Somatic complaints such as headache; lessened sleep (insomnia), or excessive sleep; loss of energy; change in appetite; decreased sexual drive. The medical workups are usually negative here and these somatic symptoms are the most common manifestation of depression in India.
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Anxiety and restlessness
People with chronic and severe depression may also show delusions, hallucinations, agitation, and complete withdrawal from activities. A particular section may describe symptoms of a medical illness but the symptoms cannot be fully explained by an actual physical disorder. Termed as hypochondriasis, this is a form of mental illness where these people are not faking or lying about their symptoms, rather they truly believe they are sick.
Suicidal ideation is often related with major depression. However, suicidal behaviour indicates deep unhappiness but not necessarily mental disorder. Many people with mental disorders like depression are not affected by suicidal behaviour, and not all people who take their own lives have a mental disorder.
5. Management
Medical
Depression associated with reactive disorders usually does not call for drug therapy and can be managed by psychotherapy and the passage of time. Drug therapy is suggested in severe cases or those having a family history of major depression or a past history of prior episodes.
The antidepressant drugs may be conveniently classified into three groups:
(1) Selective Serotonin Reuptake Inhibitors (SSRIs) and atypical antidepressants. These are the newer antidepressants used as first line agents.
(2) Tricyclic antidepressants (TCAs). The older TCAs have a narrow therapeutic index, but the newer drugs have a wider margin of safety.
(3) Monoamine Oxidase (MAO) Inhibitors. The MAO inhibitors are generally used as third-line drugs for depression (after a failure of SSRIs, TCAs, or the atypical antidepressants) because of the dietary and other restrictions required. Always ask your doctor before their use. The medication trial should be monitored for worsening mood with patient assessments every 1–2 weeks. If successful, the medication should be continued for 6–12 months at the full therapeutic dose before tapering is considered. If the response is inadequate the best alternative is to switch to a second-line agents. If the medication is being tapered, it should be done gradually over several months, monitoring closely for relapse.
In all cases of pharmacologic management of depressed states, caution is indicated for close follow-up. Combining two antidepressants, or adding an antipsychotic to an antidepressant, also requires caution and should only be done after psychiatric consultation.
Psychotic depression should be treated with a combination of an antipsychotic and an antidepressant such as an SSRI at their usual doses. Major depression with atypical features or seasonal onset can be treated with an MAO inhibitor or an SSRI with good results.
Electroconvulsive therapy (ECT)
ECT is effective in all types of depression and will also rapidly resolve a manic episode. It is also very effective for postpartum depression and severe depression—particularly the delusions and agitation commonly seen with depression in the elderly. It is indicated when medical conditions preclude the use of antidepressants, nonresponsiveness to these medications, and extreme suicidality.
Other medical treatments
Phototherapy is used in major depression with seasonal onset. Megavitamin treatment, acupuncture, and electrosleep are of unproved usefulness for any psychiatric condition. Hospitalization is necessary if suicide is a major consideration or if complex treatment modalities are required.
Psychological
Depression-specific psychotherapies help improve self-esteem, increase assertiveness, and lessen dependency. Interpersonal psychotherapy, cognitive behavioural therapy and problem-solving treatment for depression has shown efficacy in the treatment of acute depression, helping patients master interpersonal stresses and develop new coping strategies.
Social
Relaxation therapy and physical activity along with the help of family, employer, or friends is often necessary to mobilize the patient who experiences no joy in daily activities and tends to remain uninvolved. Use of day treatment centers or support groups of a specific type as well as enrolment in alcohol treatment programs certainly help.
Behavioural
Behavioural techniques, including desensitization, may be used in problems such as phobias where depression is a by-product. Behavioural counselling to family members or others can also help.
The content of this module has been validated by Dr Satendra Singh, University College of Medical Sciences, Delhi on 15/10/2014
