Depression | A Mental Health Disorder | QuadBloggers

Depression is a state of depressed mood on a daily basis for a minimum duration of 2 weeks.

• It is characterized by sadness, indifference, apathy, or irritability and changes in sleep patterns, appetite, and weight.

Criteria for a Major Depressive Episode:

A) If five or more of the following symptoms are present during the same 2 week period and represent a change from previous functioning:

1. Depressed mood most of the day, nearly everyday, as indicated by either subjective report. (feels hopeless, sad, empty) or observation made by others.
2. Marked diminished interest or pleasure in almost all activities throughout the day, nearly everyday.
3. Significant weight loss when not dieting or weight gain or decrease or increase of appetite almost everyday of more than 5 % of body weight a month.
4. Insomnia or hypersomnia almost everyday.
5. Psychomotor agitation or retardation almost everyday, usually observed by others.
6. Fatigue or loss of energy almost everyday.
7. Feelings of worthlessness or excessive or inappropriate guilt which may be delusional, nearly everyday.
8. Diminished ability to think or concentrate, or indecisiveness, nearly everyday, either by subjective account or observed by others.
9. Recurrent thought of death, recurrent suicidal ideation without a specific plan, or a suicide attempt, or a specific plan to commit suicide.

B) The symptoms cause clinically significant distress or any impairment in social, occupational, or other important areas of functioning:

C) The episode is not attributable to the physiological effects of a substance or another medical condition.

D) The occurrence of major depressive episode not explained by seasonal affective disorder, schizophrenia or any other psychotic disorders.

E) No manic episode ( Sustained period of abnormally irritable mood) or hypomanic ( State of increased energy , exhilaration and irritability ) episode.

Clinical manifestations for Depression:

• According to studies, approximately 15% of the population experience a major depressive episode at some point of life
• When a patient suspects the presence of a major depressive episode, the initial task is to determine whether it represents unipolar or bipolar related issues or use of substance abuse.
• Physicians should also assess the risk of suicide by specific and direct questioning as people are often reluctant to verbalize such thoughts without prompting.
• If the patient has past of history suicidal attempts, profound hopelessness, medical illness or any substance abuse, ,immediate care, by referring the patient to the mental health specialist for further evaluation.
• Patient should specifically probe each of these areas in an empathic and hopeful manner, being sensitive to denial, and possible minimization of distress.
• Suicidal risk usually increases with the presence of anxiety, agitation and panic.
• Unipolar depressive disorders usually begin in early adulthood and recur episodically over a period of time.
• 50-60% of people who have already had episodes have 1 or 2 recurrences. Multiple recurrences can lead to be a little fatal.

Other symptoms of Depression:

• In elderly patients, depressive symptoms, associated with cognitive deficits mimicking dementia known as pseudodementia.
• A seasonal pattern of depression, called seasonal affective disorder, may manifest with onset and remission of episodes at predictable times of the year.
  • This episode is more common in women.

Depression in association with medical illness:

• Depression in context of a medical illness is difficult to evaluate.
• Antihypertensive drugs, anticholesterolemic agents and antiarrhythmic agents are common triggers of depressive symptoms.
• In cardiac patients, 20 to 30% of the population suffer from depressive disorders with higher concentrations experience depressive symptomatology when self-reporting scales are used.
• Simultaneously, depressive symptoms like unstable angina, cardiac bypass surgery and myocardial infarction affect a large group of population.
• In cancer patients, pancreatic cancers are considered to be one of the major reasons for 40-50% of depression.
• Psychotherapeutic approaches, particularly group therapy have shown promises to help patients with short term depression, anxiety and pain symptoms.
• In neurologic disorders, depression is frequently observed particularly Cerebrovascular disorders, Parkinson’s disease, Dementia, Multiple Sclerosis and Traumatic brain injury.
• All classes of antidepressant agents are effective against depressions.
• In diabetic patients, depression is seen to be present in 8 to 27% , with the severity of the mood state corelating with the level of hyperglycemia and the presence of diabetic complications.

Other causes:

• Additionally, in hypothyroidism, features of depression are frequently associated with symptoms of depressed mood and memory impairment.
• Patients with subclinical hypothyroidism can also experience symptoms of depression and cognitive difficulty that respond to thyroid replacement.

Treatment:

• Medical Management of Major Depressive Disorder:
  • Determine whether there is a history of a good response to a medication in the patient or a first-degree relative. If yes, then consider treatment with this agent if compatible with considerations.
  • Evaluate patient characteristics and match to drug.
  • Consider health status, side effects profile, convenience, patient preference, drug interaction risk, suicidal risk, and medication compliance history.
  • Begin new medication at 1/2 to 1/2 target dose if the drug is a TCA ( Tricyclic antidepressant ), Bupropion, Venlafaxine or Mirtazapine or full dose as tolerated if drug is an SSRI.
  • If side effects prevail over the use of medication, then evaluate the possibility of tolerance and consider temporary decrease in dose or adjunctive treatment.
  • If the side effects continue in spite of measures, taper the drug over 1 week and initiate a new trial.
  • Consider potential drug interactions in choice.
  • Evaluate the response after 6 weeks at target dose. If the response is inadequate, then increase the dose in stepwise fashion as tolerated.
  • If there’s inadequate response after maximal dose , consider tapering and replacing with new drug vs adjunctive treatment.
  • Provided the drug is a TCA, obtain plasma levels to guide further treatment.

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Please refer this book for a detailed description of the disease : Harrisons book of internal medicine