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Overview

Depression

  1. What is Depression?
  2. Types of Depression
  3. Causes of Depression
  4. Symptoms & Diagnosis of Depression
  5. Treatment of Depression
  6. Practical Advice for Depression
  7. Related Conditions


What is Depression?

Depression is a mood disorder, which manifests itself through emotional symptoms such as extreme sadness, demoralisation, decreased self-esteem, suicidal thoughts and somatic symptoms such as the loss of appetite, a decrease in body weight, sleep disturbances (insomnia or sleeping too much).

Clinical depression (also known as major depression or major depressive disorder) is the most 'severe' form of depression with symptoms that persist longer than six months and it is not due to (caused by) psychoactive substances or organic mental disorders.

Depressive episodes may start with natural reactions of sadness and despair due to negative events such as bereavement or others such as divorces or separation; although if it lasts beyond six months or is so incapacitating it can lead to a diagnosis of major depression.

Major depression is a very common problem, estimated to affect 300 million people worldwide, and being, according to WHO, the leading cause of global disability. Studies have reported that at least 10-20% have suffered depressive episodes at some stage of their life, in many cases, they have never been diagnosed or treated as such. Another common problem is that it is estimated that half of them quit treatment before the six months recommended by the experts, resulting in a greater number of relapses and an increased chance that the depressive disorder becomes chronic.


Types of Depression?

Doctors describe depression by how serious it is:

  • mild depression – has some impact on your daily life
  • moderate depression – has a significant impact on your daily life
  • severe depression – makes it almost impossible to get through daily life; a few people with severe depression may have psychotic symptoms

The different types of depression are classified according to the symptoms that you may be living with:

Mild Depressive Episode

It presents two or three symptoms including a depressive mood that is not usual for you and is constant throughout the day and persists for at least 2 weeks. You may have a loss of or lack of interest in previously enjoyable activities, increased fatigue, or loss of normal vitality. Despite these symptoms, you are generally able to continue your usual activities.

Moderate Depressive Episode

In addition to the above, you may feel a sense of a self-esteem and self-confidence as well as an unjustified feeling of inferiority prolonged over time, disproportionate self-reproach and excessive and inadequate guilt. 

Your ability to concentrate and think may be reduced along with indecisiveness. You may find it hard to sleep and your body weight may have either dramatically reduced or increased over a short period of time. You may find it very difficult to fulfil your daily activities and may have 

Severe Depressive Episode

You are likely to find it difficult to do anything and may be having thoughts of death or suicide or suicide attempts. It is essential that you seek help and you may even require hospitalisation for your own wellbeing especially if you feel like you may have lost touch with reality and who you are and are experiencing hallucinations and/or delusions (psychotic depression).


Causes of Depression?

Studies seem to suggest that the main causes of depression are genetic, physiological, personal and environmental factors:

Genetic factors

A history of depression in the immediate family (parents and siblings) increases your probability of depression by 25-30%. In several studies, it has been determined that in monozygotic twins there is a 50% probability that one of the siblings will experience depression if there are symptoms in the other twin. This percentage is reduced to 25% in the case of dizygotic twins.

Physiological factors

Studies have shown that the onset and chronicity of depression may be related to a decrease in the levels of serotonin at the level of neural junctions (in the brain). For this reason, in the treatment of depression, a group of drugs, selective serotonin reuptake inhibitors, whose function is precisely to modify the levels of serotonin that are altered in these individuals, is sometimes used. There is also a group of diseases closely linked to the onset of depression, most of them related to endocrine disorders such as:

- Migraine

- Diabetes

- Hyperthyroidism

- Cushing's syndrome

- Addison's disease

- Hyperprolactinemic Amenorrhea

Personal Factors

It has been shown that there is a significantly higher percentage of depression in women than in men. Some studies have also suggested that age is also an influential factor, and the range between 35 and 45 years is the one with the highest incidence of depression. Pregnancy and postpartum are vital stages for women with an increased risk of developing depression due to hormonal and physical changes. For some people, an upsetting or stressful life event, such as bereavement, divorce, illness, redundancy and job or money worries, can be the cause. People often talk about a \"downward spiral\" of events that leads to depression. For example, if your relationship with your partner breaks down, you're likely to feel low, you may stop seeing friends and family and you may start drinking more. All of this can make you feel worse and trigger depression. You may be more vulnerable to depression if you have certain personality traits, such as low self-esteem or being overly self-critical. This may be because of the genes you've inherited from your parents, your early life experiences, or both. Becoming cut off from your family and friends can increase your risk of depression.

Environmental factors

Factors that may increase the appearance of depressive symptoms include stress, anxiety, an inability to address problems etc. Depression may be likely if you are dependent on or habitually consume alcohol, tobacco, drugs, and so on. A situation of few or no interpersonal relations especially potentiates these factors.


Symptoms & Diagnosis of Depression?

The most widely used organisation at the clinical and research levels are those reflected in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) and the 10th International Classification of Diseases (ICD-10).

According to the ICD-10 classification, a list consisting of ten general depressive symptoms for diagnosis is used, and a larger list for the classification of the depressive episode as mild, moderate or severe (having the presence or absence of psychotic symptoms) is used. In general, there must be at least two of these three typical symptoms of depression:

Symptoms of Depression

- Psychologically, a depressive mood or a low mood not usual for you that is constant throughout the day and maintained almost constantly.

- Socially, a loss of or lack of interest in previously enjoyable activities

- Physically, increased fatigue, or loss of normal vitality

As a rule, and based on certain scales or questionnaires to which patients are subjected, they usually refer to symptoms relating to a depressed mood, with sadness and hopelessness, without interest in their usual activities, with less energy or energy so low that they cannot cope in their day to day life. The feeling of guilt can also appear in some cases reactive to certain situations that have originated the picture.

From the physical point of view, you may feel slow in your movements, sometimes with difficulty concentrating and a loss of appetite and sleepiness (i.e. you may have insomnia, but in some cases, you may be sleeping too much)

The crucial point in the symptomatology of the depressed individual is usually suicidal ideation, that is, the thought with which to end your life, and even try doing so.

It is vital to recognise factors that may enhance your idea of wanting to commit suicide, such as living alone, having a family history of suicide, having previous attempts, delusional symptoms, and so on.

Diagnosis of Depression

If you experience symptoms of depression for most of the day, every day for more than two weeks, you should seek help from your GP especially if you have symptoms of depression that aren't improving, you find your mood affects your work, other interests, and relationships with your family and friends snd especially if you have thoughts of suicide or self-harm

There are no physical tests for depression, but your GP may examine you and carry out some urine or blood tests to rule out other conditions that have similar symptoms, such as an underactive thyroid.

The main way your GP will tell if you have depression is by asking you lots of questions about your general health and how the way you're feeling is affecting you mentally and physically so try to be as open and honest as you can be with your answers. Describing your symptoms and how they're affecting you will help your GP determine whether you have depression and how severe it is.

Any discussion you have with your GP will be confidential. This rule will only ever be broken if there's a significant risk of harm to either yourself or others, and if informing a family member or carer would reduce that risk.

The ICD-10 establishes that a depressive episode is diagnosed through the following parameters:

- Depressive mood, lasting no less than two weeks

- Situation not attributable to the use of psychoactive substances or to the presence of some organic mental disorder.

- A decrease or disappearance of interest and ability to enjoy things that were previously pleasant.

- An absence of emotional responses to events that usually trigger reactions

- Sleep disturbances: Inability to sleep, to maintain sleep for more than two consecutive hours, or to wake up at least two hours before the scheduled time is especially frequent

- Progressive worsening during the day of depressive mood

- Appearance of slowness in motor functions or agitation.

- Decreased appetite

- Decreased body weight due to dietary lack of control (marked increase or decrease in appetite) of at least 5% in the last month evaluated.
Marked decline or lack of sexual appetite

- Loss of self-esteem and self-confidence with unjustified feeling of inferiority prolonged over time

- Excessive and inadequate feelings of guilt

- Thoughts of recurring death or suicide, including attempts

- Decreased ability to concentrate and think. It is often accompanied by a lack of decision

In this sense, the role of the family in detecting the symptoms of depression is also very important.


Treatment of Depression?

Once you have been diagnosed with depression, you will likely initiate treatment, in almost all cases this will be a combined action of pharmacological therapy with psychological support.

Your doctor should inform you of the duration of treatment for your depression, the benefits of that treatment, and the side effects of any medication that may develop throughout the treatment.

Pharmacological Treatment of Depression

In general, the pharmacological treatment of depression is usually limited to moderate or severe depressive symptoms. If you are diagnosed with mild depression, pharmacological therapy is often not used because of its narrow benefit-risk profile. It is only recommended in case of failure of other therapies, associated medical or psychological problems, or previous history of moderate or severe depression.

In individuals with moderate or severe depression, pharmacological therapy is considered a first-line treatment, although a study showed that there are 38% of patients who, after 6-12 weeks, have no response to treatment, and in 54% of patients there is no remission of symptoms.

Antidepressants

The major groups of antidepressant drugs are:

Tricyclic Antidepressants

TCAs have a good efficacy profile by blocking the reuptake of two compounds of interneuronal communication (noradrenaline and serotonin), although they present a high rate of side effects. They are contraindicated in individuals with a recent history of myocardial infarction (heart attack), as well as in individuals with cardiac arrhythmias, benign prostatic hyperplasia, open angle glaucoma, renal or hepatic impairment, and epilepsy or a history of seizures.

Selective Serotonin Reuptake Inhibitors

SSRIs are very specific inhibitors of serotonin reuptake with little or no impact on the rest of the neurotransmitters, which gives them great tolerability (the main side effects described are nausea, sweating and changes in body weight ), and therefore are the group most prescribed in primary care.

Monoamine Oxidase Inhibitors

MAOIs are more or less selectively inhibit monoamine oxidase A or B. They have a rather negative side effect profile and therefore are used as second-line treatments in case of lack of effectiveness of other alternatives more secure.

Other antidepressant drugs

These focus mainly on the reuptake of serotonin or noradrenaline, although new therapeutic lines act on serotonin and α 2 -adrenergic receptors.

Stages of Psychopharmacology in Depression

There are specific guidelines for general follow-up when establishing pharmacological treatment in a depressive condition. The main ones are:

All antidepressants require a period of therapeutic latency (time from onset of treatment until symptoms begin to appear) from one to three weeks.

Treatment should begin at low doses and gradually increase the dose if necessary.

At 3-4 weeks after the treatment of depression, it is necessary for your doctor to review the treatment in order to evaluate your progress, to check whether side effects have occurred and to modify the dose if necessary.

If at 6 to 8 weeks of taking the maximum dose you do not indicate an objective improvement, your doctor will assess the suitability of the antidepressant, perhaps switching to another type in either the same family or a different family. In some individuals, it may be necessary to combine antidepressants with hypnotics or anxiolytics for a period of time.

The antidepressant treatment must be stopped progressively, decreasing the dose gradually to avoid the appearance of discontinuation effects.

Special Considerations in Depression Treatments

Seniors: Depression in these individuals usually present with a greater number of somatic symptoms and anxious component, which makes their diagnosis very difficult. Serotonin reuptake inhibitors are commonly prescribed primarily, and tricyclic antidepressants are often contraindicated. It is necessary to halve the dose indicated for adults in the elderly over 70 years, and to a third in the elderly under 70 years, because their cognitive ability can be altered more easily, and are more sensitive to the sedative effect and hypotension orthostatic (lowering of tension upon incorporation after lying down) common in certain antidepressants, which increases the risk of falls.

Pregnancy: in the absence of studies on the safety of antidepressants during pregnancy, it is tried, as much as possible, to avoid the use of these drugs, especially in the first trimester. In the case of suicide risk or conduct that may harm the fetus, serotonin reuptake inhibitors or tricyclic antidepressants are prescribed. During breastfeeding, it is important to note that all groups of antidepressants are excreted in breast milk.

Parkinson's disease: the only drugs studied in patients with Parkinson's are tricyclic antidepressants, which have a beneficial effect on them due to the anticholinergic effect. Serotonin reuptake inhibitors are also effective.

Epilepsy: Serotonin reuptake inhibitors are of choice in patients with epilepsy because of their lower proconvulsive effect.

Psychotherapeutic Treatment of Depression

Psychological therapies are often used in the treatment of depression e.g. cognitive-behavioral therapy (CBT) and interpersonal psychotherapy (IPT).

Cognitive-behavioral therapy has proven to be as effective as interpersonal psychotherapy (slower in achieving goals than CBT and pharmacotherapy combined) and pharmacological therapy, making it the psychotherapeutic therapy of choice in the management of depression moderate, severe or resistant.

The duration of therapy will vary depending on the type of depression diagnosed and your personal situation. If you have severe or chronic depression, if psychotherapeutic therapy is associated with pharmacological treatment, the effectiveness will always be superior to either of these therapies alone.

Cognitive-behavioral therapy, associated with maintenance treatment, contributes to an increase in its effectiveness in order to avoid the occurrence of relapses. This is especially beneficial for those with a history of relapse, or who have residual symptoms since they are the ones who are at greater risk of suffering from depressive episodes again.

Other Treatments for Depression

Electroconvulsive Therapy (ECT): This therapy consists of causing a generalised crisis of activity (a seizure), through electrical stimulation of the central nervous system. In spite of being a devalued and reviled therapy in its beginnings, it is currently applied under anaesthesia and is considered effective in adult patients with severe or resistant depression.


Practical Advice for Depression?

Guided self-help: its objective is for you to acquire skills in order to manage the symptoms you experience. Although good efficacy has been demonstrated in individuals with mild-to-moderate depression, the long-term effects are not known

Physical exercise: the ability of physical exercise to improve personal well-being, both physical and psychic, is demonstrated. In individuals with mild to moderate depression, an exercise program of moderate intensity, 40-45 minutes, 2-3 times a week, over a period of 10 to 12 weeks, could have a clear improvement in depressive symptomatology.

St. John's Wort (Hypericum perforatum): Its antidepressant properties have been found in numerous studies. Please note that it presents interactions with other medicines and should always be taken under the supervision of a health professional.


Related Conditions

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Anorexia Nervosa

Bulimia Nervosa

Bipolar Disorder

Generalised Anxiety Disorder

Social Anxiety Disorder (Social Phobia)