Clinical Conditions

Depression

Introduction

Depression is the commonest psychological manifestation, experienced by all either sometimes as a personal experience or at other times through depression in a family member.

At some time, everyone experiences sadness, but that is not depression. Sometimes we feel low from working hard, often disappointed and discouraged when faced with serious issues. This too, is not depression. Having adjusted to the stress these feelings usually pass within a few days or weeks. What signifies depression is only if these feelings linger, intensify, and begin to interfere with daily work, family or school responsibilities. Depression not only interferes with normal functioning but also causes frequent issues with work family and social adjustment. It affects how the person thinks feels and behaves.

Depression

Impact of Depression:

  • Emotional upsets
  • Disrupts daily living of people
  • Families and friends adversely affected
  • Absenteeism and reduced productivity at work

Depression can affect anyone. Once identified and diagnosed, most people can be successfully treated. Depression often goes undiagnosed, since most often the manifestations mimic physical ailments like appetite and sleep disturbances.

Since symptoms could wrongly be interpreted as physical ailments depression therefore often goes untreated. Nearly two-thirds of depressed people do not receive proper treatment, reasons being:

  • Symptoms are not recognized as depression.
  • Individuals with depression wrongly labelled as weak or lazy.
  • Myths, social stigma and taboo most important cause to avoid seeking treatment.
  • Dysfunctional individuals often cannot reach out for help.
  • Symptoms often misdiagnosed as physical ailments
  • While Individual symptoms get attention and treatment, depression as underlying cause goes untreated.

It is imperative to remember that 80% of cases with appropriate treatment can make significant improvement in their mood and life adjustment.

What is depression?

Depression affects the body, mood, and thoughts. It affects the way you think and feel about yourself and the world around you not just the way you eat and sleep. A depressive disorder is not the same as passing blues. It is neither a sign of personal weakness or a condition that can be willed or wished away. Those with depression just cannot pull themselves together and get or feel better. If untreated symptoms can last for weeks, months, or years. Treatment does help most people who suffer from depression.

The symptoms of depression may vary in different individuals also largely depend on the severity of Depression. The following changes are seen in those with depression;

  • Changes in Thinking – Inability to concentrate or make decisions. Sometimes difficulty remembering tasks, forgetting things all the time. Negativity with pessimism, low self-esteem, guilt, and self-reproach and criticism are all common. Some people have self-destructive and suicidal thoughts during a more serious depression.
  • Changes in Feelings –Sadness without reason, apathy for activities they once found pleasurable. Tired and listless all the time. Irritability and anger outbursts especially in teens and adolescents may be common. Feelings of helplessness and hopelessness in severe cases of depression.
  • Changes in Behaviour - Social withdrawal, increase or loss of appetite, frequent bouts of weeping are common. Lack and disinterest in sexual activity. Others may have difficulty getting out of bed, lack personal hygiene, inability to complete daily chores or may lament and express temper outbursts.
  • Changes in Physical Well-being –Tiredness and chronic fatigue, despite increased hours of sleeping is common. Some individuals have insomnia, or don't sleep soundly. These individuals may take a long time to get sleep, may wake up frequently at night. Even after a good sleep they are tired and never fresh after waking. Appetite reduces, physically get slowed down by depression, and present with persistent aches and pains. Some cases also have symptoms of restlessness, and inability to sit still.

Causes of Depression

  • Chemical imbalances in the brain.
  • Biological vulnerability since depression known to run in families.
  • Psychological Factors: People who have low self-esteem, who are readily overwhelmed by stress and who consistently view themselves and the world with pessimism are more prone to depression.
  • A serious loss, chronic illness, persistent relationship problems, financial or family crisis, work place stress, or any life change which is unwelcome triggers depression.

Diagnostic information

Psychological evaluation helps identify a depressive illness, and its nature. An evaluation will include a comprehensive history of symptoms, i.e., origin, duration and progress, history of substance and alcohol use, and if there are thoughts of suicide or death. A mental status examination will evaluate the range of psychological symptoms. Lastly any family history of depression. The above history would help make diagnosis and decide the treatment of choice.

Types of Depression

Depression can be classified based on the intensity, duration & the cause of symptom;

  • Major Depression – This form of depression has the most number of symptoms often severe in nature., but there are significant differences amongst different cases in the symptoms and severity. You do not need to feel suicidal or have attempted suicide to have a major depression.
  • Dysthymic Disorder – When symptoms of depression last for two years or more with low to moderate levels of symptoms. The symptoms are less severe as compared to major depression, also they are more enduring and resistant to treatment. Major depression may develop in a few with dysthymic depression.
  • Unspecified Depression - It includes people with chronic, moderate depression, not present for long enough period to classify for a diagnosis of a dysthymic disorder. Though serious in nature but not quite severe enough to be diagnosed as major depression.
  • Adjustment Disorder, with Depression - Major life stressor or crisis resulting in depression mark diagnosis of adjustment disorder.
  • Bipolar Depression - This type has frequent mood swings, its symptoms express symptoms both of tide and ebbs i.e. both highs and lows, it has a variety of other significant symptoms often not expressed in other forms of depression.

Major Depression

Major depression can occur once and therefore be termed as single episode depression. There are those who have recurring episodes of depression followed by periods of remission for several years without depression, this may be followed by another episode, often in response to another trauma.

Symptoms of Depression

For major depression to be diagnosed atleast five of the below mentioned symptoms should be present for more than two weeks;

  • Persistent sadness and anxiety
  • Feeling hapless, hopeless, helpless or guilty
  • Extreme Pessimism and negativity
  • Lack of interest even for pleasurable activities.
  • Decreased energy persistently tired
  • Lack of memory and loss of concentration
  • Excessively Irritable and restless
  • Excessive or lack of Sleep
  • Loss of or increase in appetite
  • Suicidal ideation and thoughts of death.

Bipolar Depression

What is Bipolar Disorder?

The hallmark of bipolar disorders as compared to other mood disorders bipolar disorder is the presence of at least one manic episode. It is a chronic condition since majority of individuals who have one manic episode also frequently have additional episodes in the future. Symptoms manifest in adolescence or early adulthood and continues throughout life. Since the symptoms and manifestations are episodic It is often not recognized as a psychological problem, consequently, those who have it often suffer needlessly for years without treatment. Untreated cases often may have marital breakups, job loss, substance abuse like alcohol and drugs, and suicide may result in the course of chronic ailment.

What is a manic episode?

A manic episode is when client is on his ‘Highs’, it’s an abnormally elevated, expansive or irritable mood, unrelated to substance abuse or a medical condition, that lasts for at least a week, and includes a number of disturbances in thinking, feeling and behaviour, resulting in significant life adjustment problems.

The various mood states in manic-depressive illness should be perceived as a spectrum or continuous range. At one end is severe depression and other end mania, which in-between have shades of moderate depression; then come mild and brief mood disturbances often referred as "the blues," then normal mood & then hypomania which is a mild form of mania.

Here below are the features of depressive and manic episodes;

Features of a Depressive Episode

  • Persistent sad and anxious mood
  • Feeling hapless hopeless, helpless or guilty
  • Extreme Pessimism and negativity
  • Lack of interest even for pleasurable activities.
  • Decreased Energy and always tired.
  • Lack of memory and loss of concentration
  • Excessively Irritable and restless
  • Excessive or lack of Sleep
  • Loss of or increase in appetite
  • Suicidal ideation and thoughts of death.

Features of a Manic Episode

  • Extreme irritability and distractibility.
  • Excessive euphoric feelings
  • Bizarre and unusual behaviour with significant risk-taking
  • Rapid Talking, thinking, agitation with increased energy
  • Poor sleep
  • Unrealistic belief in one's own abilities
  • Increased sex drive
  • Provocative or obnoxious behaviour
  • Substance abuse
  • Poor Judgement and Insight

Dysthymic Disorder

Dysthymic Disorder manifests as chronic depression, less severe than a major depression. Dysthymic disorders present as persistent depressed mood almost daily for at least two years and do not meet the criteria for major depression. Lack of energy, sleep or appetite disturbances and poor self-esteem are usually part of the symptomatology.

Medical treatment and psychotherapy is effective in reducing the symptoms of depression, and assisting them managing and maintaining their routine.

Identifying Dysthymic Disorder

Depression causes changes in thinking, feeling, behaviour, and physical well-being.

  • Changes in Thinking – Inability to concentrate or make decisions. Torpidity, generalised slowness, difficulty remembering tasks, forgetting things all the time. Negativity with pessimism, low self-esteem, guilt, and self-reproach and criticism are all common. With more severe forms of depression self-destructive and suicidal thoughts are common.
  • Changes in Feelings – Sadness without reason, apathy for activities they once found pleasurable. Tired and listless all the time. Irritability and anger outbursts especially in teens and adolescents may be common. In severe cases feelings of being hapless, helpless and hopeless.
  • Changes in Behaviour - Social withdrawal, increased or poor appetite, frequent bouts of weeping are common. Lack and disinterest in sexual activity. Others may have difficulty getting out of bed, lack personal hygiene, inability to complete daily chores or may lament and express temper outbursts.
  • Changes in Physical Well-being - Prolonged and chronic fatigue, despite sleeping for long hours. Disturbance in pattern of sleep some with insomnia some don’t sleep sound. Appetite reduces, physically complain of aches and pain and get slowed down by depression. Others are restless, and can't sit still on account of agitation

Depression, Not otherwise specified

This diagnosis is given to those cases who are obviously depressed, but do not fit into any of the above. This category includes; serious depression, but not severe enough to be labelled as major depression. This also includes those with mild to moderate depression, but this is not classified under dysthymic disorder since duration is less than two years. Those having some traumatic event, and depression has continued longer than expected for adjustment disorder with depression are also diagnosed under this category. Diagnosis helps predict the expected duration and outcome of treatment.

Adjustment Disorder, with depressed mood

Also referred as reactive depression. Here the symptoms of depression develop in response to a specific and identifiable psychosocial stressor. Adjustment disorder symptoms should be treated and disappear within six months following the end of the stress. If the symptoms persist longer it qualifies in the above category.

Helping Yourself

Depression is often associated with feeling hapless, helpless, and hopeless. These negative thoughts and feelings make some people feel like giving up. Patients should realise that these negative views are part of depression, and inaccurate. These negativity passes away with treatment. Cognitive psychotherapy, designed to change the negative thinking associated with depression is known to help with Depression.

In the meantime:

  • Avoid taking up new tasks, Set reasonable goals.
  • Accomplish what you can do, set priorities by breaking up large tasks into small ones.
  • Do not expect too much and too soon, be reasonable with yourself or this will only increase feelings of incompetence.
  • Being in company is helpful than being alone.
  • Do things that previously gave you pleasure like going to movies, exercises and participating in religious / social activities.
  • Getting and feeling better takes time be patient.
  • Avoid taking major life decisions especially without consulting significant others. If possible, postpone important decisions until your depression has lifted.
  • Do not believe and accept the negativity which comes with depression. It will go once your depression responds to treatment.
  • Getting professional help is the best recourse to beating depression. It helps you recover faster.

Helping the Depressed Person

  • The best way to help him / her is to get them to take appropriate treatment. This may involve either visiting a mental health professional with them, encouraging them to continue treatment or monitor if prescribed medications are taken properly.
  • The second most important way to help is to offer emotional support. Unconditional Praise, Patience and Encouragement, provides hope and happiness.
  • Engage them in activities that once gave them pleasure such as hobbies, sport or religious/cultural activities.
  • Reassurance that this too will tide away with time is important rather than telling them that blaming them for not being at par or telling they are lazy.

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