Depression Essay

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Depression

Everybody’s mood varies according to events in the world around them. People

are happy when they achieve something or saddened when they fail a test or lose

something. When they are sad, some people say they are ‘depressed’, but the

clinical depressions that are seen by doctors differ from the low mood brought

on by everyday setbacks. Psychiatrists see a range of more severe mood

disturbances and so find it easier to distinguish these from the normal

variations of mood seen in the community. General practitioners (GP’s) need to

be sensitive enough to distinguish emotional reactions to setbacks in life from

anxiety syndromes, somatisation and clinical depressions. The general idea is

that anxiety disorders, depressive episodes, somatisation and adjustment

reactions are all different entities, but in practice it is not always that

clear-cut. Major depression, as defined by psychiatrists, is unfortunately

relatively common.

What is depression?

The term “affect” refers to one’s mood or “spirits.” “Affective disorder” refers

to changes in mood that occur during an episode of illness marked by extreme

sadness (depression) or excitement (mania) or both. Depression is a disorder of

affect. Affective disorders are predominantly disturbances of mood that are

severe in nature and persistent despite the influence of external events.

Depression is characterized by severe and persistent low mood, which is often

unresponsive to the efforts of friends and family to cheer the sufferer up.

Patients who suffer with repeated episodes of depression have a Recurrent

Depressive Disorder. Depressive episodes can be classified into mild, moderate,

and severe types, with or without psychotic symptoms. To be classified as

depression, an episode must last more than two weeks. A condition where the

mood is persistently low, but does not quite fulfill all the criteria for a

depressive episode, is sometimes called “dysthymia.”

Community studies have found that depression is prevalent between 5 and 20% of

all people. About 10% of people over age 65 will have a major depressive

episode. The incidence of depression is higher in women and in urban settings

rather than rural settings.

Clinical features of depression

Mild depressive episodes typically include features such as:

Sadness and crying,

Loss of interest in and loss of enjoyment of life (anhedonia),

Poor attention and concentration,

Low self-esteem and ideas of unworthiness,

A bleak view of the future and the world in general,

Poor sleep and appetite.

People with mild depressive episodes find it difficult to continue with their

work and social lives, but usually continue to function, although less than

normal. Moderate depressive episodes have a wider range of symptoms, which are

present usually to a greater degree. Sufferers find it very difficult to

function normally at work or home.

Severe depressive episodes typically may also include features such as:

Great distress and agitation,

Slowed thought and movement (psychomotor retardation),

Ideas of guilt,

Suicidal fantasies or plans which may be acted upon,

Pronounced somatic symptoms,

Psychotic symptoms.

People with severe depressive episodes find it impossible to continue with their

work, domestic and social lives, and usually cease to function in these areas.

Depression is often accompanied by slowing of thought processes and biological

features of everyday life which differ from a normal sense of sadness. Crying

is a frequent symptom, although some individuals are reluctant to admit this,

and others feel so depressed it that is as if they have ‘gone beyond crying’.

Suicidal ideas occur in most depressed people, and asking about these is a

crucial aspect of their assessment. Depressed patients often find it a relief to

talk about these ideas with their doctor. Asking about suicidal ideas is a

sequential process, beginning with questions about the severity of the low mood.

The doctor can then ask if the patient has ever felt that life is not worth

living. A ‘yes’ could be followed by inquiring whether the patient has ever felt

like ending their own life. Finally the doctor needs to assess if the patient

has any particular plans in mind.

Case History: Janet

Janet Gordon was aged 35 when she lost her job as a manager of a department

store. At first she looked on her period of unemployment as an opportunity to

try out activities she had previously no time for. She went hill-walking and

painting every day. Two months later she had lost interest in these things and

was despairing that she would never work again, although she had an exemplary

work record. Her sleep at night was poor and she had started going to bed

during the day. Janet cried almost daily and had lost interest in the food she

cooked. All food tasted bland, she said to her mother (who was concerned when

she saw how much weight Janet had lost). At her mother’s suggestion Janet went

to her family doctor where she complained about how tired she always felt. She

asked for some sleeping tablets to help her sleep at night.

Case History: Alan

Alan Benson was brought to the accident and emergency department by his son.

Alan had tried to hang himself from the banisters at the family home.

Fortunately the clothes’ line that he had chosen to hang himself with had broken

under his weight. When he was seen by the psychiatrist Alan had a red weal mark

around his throat from the noose. He was staring at a fixed point on the floor.

Now and then he would groan deeply and whisper to himself. He kept repeating the

words ‘I’m for it..I’m for it now.’ He would not make eye contact with the

doctor and initially refused to answer questions.

His son said that the previous week his father had stopped going to work as a

bailiff after he found out that his wife was having an affair. He had watched

her obsessively for two days, not letting her out of his sight. Then a few days

ago he had taken to his bed, and lain there for hours and hours not moving, not

speaking, not eating and not drinking. He had talked about how everything was

his fault and had at times been pleading with an unseen person to forgive him.

He felt that he had committed some unpardonable crime and that he should now be

punished.

Armed with this information the psychiatrist talked to Mr. Benson again. This

time Mr. Benson replied, even if only briefly. He said that God was telling him

that his wife had to find another man because her husband had been so evil. He

confessed that he had once had an affair himself many years before, and that God

had told him in the last week that He had punished Mr. Benson with syphilis. His

wife could be spared from the syphilis only if he killed himself. Once he was

dead, he thought, his wife could begin a clean life with another man.

Differential Diagnosis

Many physical disorders can be present with depressive illness. They include:

hypothyroidism, hyperthyroidism, Addison’s disease, Cushing’s disease,

electrolyte disturbances, alcoholism, drug abuse, carcinoma and dietary

deficiencies (B12, B1, and folic acid). Various drugs can cause depression.

Psychological disorders that may mimic depression include adjustment reactions,

anorexia nervosa, bulimia nervosa, anxiety disorders, substance abuse,

obsessive-compulsive disorder, dysthymia, seasonal affective disorder, and

abnormal bereavement reactions. Panic disorder commonly co-exists with or pre-

dates depression, (Andrade et al, 1994). Diagnosing and treating underlying

physical causes must be attempted and are key factors in the correct prognosis

of the actual cause of a persons depression.

Risk factors for depression:

In Young Adults:

Urban dwellers,

Unemployment,

Physical ill-health,

Previous affective illness,

Family history of depression,

Childhood abuse/trauma,

Loss of mother before age 11,

Looking after several young children,

No confidence,

Bereavement.

In Older People:

Bereavement of a close figure in last six months,

Loneliness (but not living alone),

Lack of Satisfaction with Life,

Female Sex.

The risk factors for older people identified above have some predictive value in

identifying people at risk of depression three years later. Life satisfaction

and bereavement help predict recurrences of depressive illness. The higher

prevalence of depression amongst women could be because women are more prone to

depressive illness biologically or because of their social roles, or could be

because male depression is under-recognized, or incorrectly labeled. However,

suicide is more common among men than women. It is worth remembering that only

50% of depressed patients who present to their GP are correctly diagnosed as

suffering with depression. Most depressed people in the community do not

receive treatment. Over 90% of depressed elderly people in the community suffer

without treatment.

Armed with knowledge of its prevalence, causes and common features, one might

assume that it is a simple task to diagnose depression in general practice

settings. Unfortunately it isn’t. Certainly having a high index of suspicion

and a professional willingness to consider the possibility of depression are

important factors in our ability to diagnose depression.Additionally patients

also have a significant part to play in enabling – or preventing us – from

arriving at a diagnosis of depression.

It is rare to find depression as a simple, unitary diagnosis in general practice.

It is much more common for patients to show a combination of problems – some

physical, others social – within which depression can all to easily be either

unnoticed, or assumed to be inevitable and therefore untreatable. Freeling et

al 1985 and Tylee et al 1993 have shown that severe depression is much more

likely to be missed if associated with significant physical illness. Moreover,

many patients have strong reservations about disclosing depression to their GPs.

Depression itself often contains feelings of hopelessness and despair. Patients

may therefore feel that there is no point in talking to the doctor about it

since there is nothing that they or anybody else can do about it. These

negative perspectives can be compounded by GPs – often unwittingly – if they

give the impression of rushing through their consultations and being unable or

unwilling to sit and listen to our patients’ concerns.

There is still a considerable stigma attached to mental illness. Many people

have a great fear of the consequences of acknowledging their depression to a

professional person: they may be ‘carted off to a loony bin’, or written off as

‘mad’. If the word ‘depression’ appears in medical notes they fear – often

correctly – that this will be prejudicial to future employment or insurance

prospects.

Fear of antidepressant medication is also a very important obstacle to

disclosure of depression. A study undertaken by the Defeat Depression campaign

showed that many people confuse antidepressants with benzodiazepines, and are

genuinely worried about becoming dependent – ‘getting hooked’ on them, and about

unpleasant effects of withdrawal. There is considerable public skepticism about

the effectiveness of antidepressants. Most patients would prefer to be offered

counseling rather than drugs, but doubt if they will be given such a choice by

their GP. Faced with this complex barrage of obstacles, it is perhaps surprising

that we ever do manage to make a diagnosis of depression! However, there are

many things that can be done to increase the chances of detection. We need to

help some patients to reattribute physical symptoms to psychological causes. If

a patient is feeling tired all the time, has no energy or interest in life and

is sleeping very badly, these chances of their being depressed are very high.

Often a direct question – ‘do you think you may be depressed?’ – is all that is

needed to move the consultation onto a psychological agenda. Sometimes it is

better to take a more indirect route. The word ‘stress’ is a very useful bridge,

since it intrinsically has both physical and mental components: ‘Are under any

extra or unusual stress at the moment?’, or ‘Do you think these symptoms might

be due to stress?’ are effective open ended questions. For those few patients

who appear reluctant to consider any diagnosis of depression it may initially be

most profitable to concentrate on its more physical manifestations – sleep and

appetite disturbance, or energy loss – without forcing the issue of their

underlying causation.

We must also accept patients’ genuine anxieties about the shame attached to

depression, and acknowledge their concerns about the harmful effects of drug

therapies. Good basic consultation skills include inquiry into patients’

expectations and fears about the nature and consequences of their problems. This

will take us a long way towards understanding not only whether our patients are

depressed, but the context and meaning that their depression has for them. Many

people experience enormous relief when their problems are explored in this way.

To a large extent, therefore, effective diagnosis is also the most crucial

aspect of effective treatment.

Management

There are two important dimensions to be considered in deciding how best to

manage depression in general practice. First, mild depression may often be

managed effectively through sympathetic exploration of the factors precipitating

it – whether physical illness, a recent personal crisis in work or relationships

– and encouragement of the patient’s own coping mechanisms and supportive

informal social networks. Moderate and severe depression have been shown to

respond to antidepressant drug therapy. As we have seen it is essential to

discuss patients’ anxieties and expectations of drug treatment before starting

it. Also, drugs should be viewed as complementary rather than alternative to

talking about depression. Problem-solving is a useful and simple skill to

develop. The first stage is the creation of a problem list. This is something

usually best done by the patient between sessions, although they may need some

help initially. The patient writes down a list of problems which he is

experiencing at present, either in terms of how he feels – miserable, tired,

bored etc. – or in terms of things he is unable to do – go to work, enjoy

hobbies, etc. He can then rank these problems in order of importance, and set

goals for overcoming them. These goals should be staged and not too ambitious.

For instance, if feeling bored is a central concern, it might be useful to

discuss which aspects of life give the most pleasure and interest – watching TV

soaps, walking the dog, having a bath, and agreeing that the patient will spend

a set amount of time each day doing just that.

Problem-solving works well in conjunction with drug therapy, and directly

addresses the sense of hopelessness that is central to depression. It enables

both doctor and patient to achieve a sense of purpose and direction, and

provides a practical means ofmonitoring and demonstrating progress. The second

dimension to the management of depression in general practice concerns the views

and experience of the doctor and the patient. GPs vary considerably in their

skills, experience and confidence in dealing with depression. Some of us will

prefer to refer early to other professional colleagues, whether counselors,

psychologists or psychiatrists, while others are more comfortable about managing

even acute and severe problems. Patients, as we have seen, may also have strong

views about the causes, effects and treatment of depression. If we are to manage

it effectively we must take these into account. When people feel they are being

listened to, and have genuine choices about what happens to them – whether they

receive counseling or drug therapy or both, whether they are referred for

psychiatric opinion or not – they are more likely to be committed to the

management plan that emerges. Many patients, even when expressing suicidal

thoughts, may prefer to be managed at home by their GP than be admitted to a

psychiatric ward: the problem then becomes one for us, in assessing the degree

of risk and responsibility that we feel able to sustain. It is worth

remembering that, involving our patients in genuine decision-making about the

management of their illness is intrinsically therapeutic. Studies of treatments

versus placebo have endorsed the value of physical therapies such as ECT

(electric-convulsive treatment or “shock therapy”) in severe depression and

antidepressants in mild, moderate and severe depression. Most depressive

illnesses respond to such treatments. Tricyclic antidepressants need to be

taken regularly in adequate doses for an adequate length of time. Inadequate

doses of Tricyclic antidepressant are linked to suicidal behavior in some

studies. Newer antidepressants (SSRIs and RIMAs) offer a relative safety in

overdose. Some psychological treatments have proven efficacy, notably cognitive-

behavioral therapy and interpersonal psychotherapy for mild and moderate

depression. Their drawbacks are that they take longer to have an effect and are

not well-standardized. There is evidence that cognitive behavioral therapy and

interpersonal psychotherapy may help maintain health when combined with

antidepressant medication, but there is as yet little evidence to suggest that

counseling alone is a suitable treatment for major depression. Where there is

evidence of continued relationship or family difficulties psychotherapy may be

particularly useful. Cases of moderate to severe depression may need vigorous

treatment by a community psychiatric team and close follow-up to help prevent

relapse and improve prognosis. Severely depressed patients with or without

psychotic symptoms require inpatient admission and may respond best to electro-

convulsive treatment.

Who to refer people to:

Counselors, psychotherapists, community psychiatric nurses, occupational

therapists, social workers and psychologists, unless also medically qualified,

are not trained to diagnose depression, recognize its origin, or formulate long-

term management plans. If referring on to one of these agencies as the sole

provider of psychological care, the onus is on the general practitioner to

diagnose the depression correctly, to be certain about its origin and to have a

clear long-term management protocol in mind. The General practitioner must

therefore be sure to have excluded physical illness as a cause of the depression

before referring on to the non-medically trained.

Prognosis

The long-term prognosis for depression is still guarded, however. Up to 15% of

patients who have had depression will go on to kill themselves. Recurrent

episodes of depression are the norm rather than the exception. Long-term studies

of lithium suggest that it may help to reduce the number of episodes and prevent

suicide. Studies of long-term use of antidepressants suggest beneficial effects.

Long-term efficacy of psychotherapy and counseling has not been proven.

Learning points: depression

Depressive illness affects 10-18% of the adult population. Depressive illness

in the community is largely untreated, because patients generally do

not seek medical help, and of those that do seek help only about 60% of

those that see

their family doctor are recognized by them as suffering from depression.

Depressive illness is treatable – over 80% of cases can be resolved with

adequate

treatment. Treatment may include antidepressants, (SSRIs, tricyclics, MIRA

drugs, or MAOIs),

ECT (for severe or delusional depression) or psychotherapy for mild to

moderate

depression (particularly cognitive therapy).

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