Depression is a common public health problem that can affect any individual. It is commoner in women and can a significant impact on the quality of life of patients if left untreated.
Most patients who suffer from depression are unwilling to admit that they are depressed making it even harder to treat. It carries with it a degree of social stigma as well, but increased awareness has made this now a health problem that can be promptly treated. There are many types of depression such as major depressive disorder, atypical depression, seasonal affective disorder and bipolar depression, just to name a few.
Here we shall quickly cover the causes, clinical features and management of major depressive disorder.
What s depression?
Depression is a condition characterised by low mood and lack of interest in performing any of the normal activities of daily living. Causes of depression can be many, and treatment options vary from patient to patient.
Causes of depression
There are a variety of causes of depression.
1. Genetic factors
Depression runs in families. Genes have now been identified that are transmitted through generations, which manifest later in life as depression. A detailed discussion on all these genes is out of the scope of this article.
2. Psychosocial stress
These can include a variety of stressors such as loneliness, loss of a loved one, chronic medical illness (such as motor neuron disease, multiple sclerosis etc.) or social isolation.
3. Drug induced
Some medications are known to cause depression such as beta blockers, steroids and narcotic drug abuse.
4. Poor family relationships
Growing up, a child needs to be nurtured and guided in order to face the world as an adult one day. Studies have shown that a poor interaction between children and their parents can result in depression at a later stage in life.
Symptoms of depression
The criteria for diagnosing depression have been set out by the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). These have been recently revised and the table below lists some of the symptoms –
|Diagnosis of Major Depressive Episode1
** A major depressive episode requires that at least 5 of these 9 symptoms be present during the same 2 week period.
Expanding on those symptoms a bit, patients with depression can either not sleep at all or sleep all the time. Patients may stop eating and lose a lot of weight, or can take up comfort eating and put on a lot of weight.
The lack of energy and constant tiredness can mean that they just are not bothered with normal daily tasks, even aspects of personal hygiene. Suicidal thoughts usually relate to ones where dying seems to be a favourable option to manage the depression, and as a result the patient may be pre-occupied with it a lot.
Patients with depression may also find the symptoms to be worse in the evening or on weekends, especially if they are trying to keep occupied in the day. However, people who are able to manage any tasks probably suffer from mild depression, but as it gets more severe, it may be that all the 9 features listed in the table above may be present.
Depression is usually diagnosed through a series of questions that cover the points highlighted in the table above. Self reporting tools are the best tools available, and probably the most common one used it the Patient Health Questionnaire-9 (PHQ-9).
However, in older patients, the Geriatric Depression scale is often used to make a diagnosis. Below is an image of the PHQ-9 and the questions asked within it to make a diagnosis.
In some cases of depression, it is important to make sure there are no underlying medical issues that have resulted in depression. Blood tests may need to be performed such as thyroid function tests, vitamin B12 levels, liver function tests and many more in order to identify a precipitating factor, if any. Brain scans may be required to rule
out any brain pathology as a cause.
Treatment of depression
There are a variety of treatments available for depression, and can differ from patient to patient.
1. Drug therapy
There are a variety of drugs that can be prescribed for patients with depression –
- Tricyclic antidepressants – Amitryptilline, Clomipramine
- Selective Serotonin Reuptake Inhibitors (SSRIs) – Citalopram, Fluoxetine, Paroxetine
- Serotonin/Norepinephrine Reuptake Inhibitors (SNRIs) – Venlafaxine, Duloxetine
- Atypical antidepressants – Mirtrazapine, Trazodone
- Mono-amino-oxidase (MAO) inhibitors – Selegeline, Tranylcypromine
These drugs are used in major depressive illnesses and can take a few weeks to show some effect in patients. Side effects can be a few, and in case they develop may require treatment to be changed or terminated.
2. Electro-convulsive therapy
ECT is a useful form of therapy where the patient is administered an electric shock under anaesthesia. However, it is only used in patients in whom other treatments have failed, those that are at a high risk of committing suicide or those who carry a high mortality risk. Treatment is effective though it can take up to 7 days to show effect.
This includes a variety of different therapies ranging from cognitive behavioural therapy, group therapy and supportive therapy all the way to interpersonal therapies and mindfulness based cognitive therapies. While these treatments may be effective individually, it is recommended that they be administered along with other antidepressant treatments. Cognitive behavioural therapy in particular is very useful, and is now offered as first line treatment for patients.
Depression can be a debilitating illness that can have a significant impact on patients and their families. Treatment options are many and require a tailored approach for each patient. If properly administered, outcomes can be very good and patients can go back to leading a normal life.
1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorder, Text Revision. 4th Edition. Washington, DC: American Psychiatric Association; 2000.