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Depression By Dr Reshma Agarwal, Psychiatrist, G B Pant Hospital, New Delhi

Ms S, a 42 year-old housewife was brought by her husband, who reported that she had been keeping unwell since a few months. It had started with difficulty in falling asleep, and a reduced appetite. Gradually, she became irritable, intolerant of noise, and began losing interest in most activities like watching T.V. and visiting friends & relatives. She was also unable to perform routine household chores, feeling tired all the time. Whenever she felt low, her family members would try to cheer her up, but she would then feel worst, often bursting into tears, at the helplessness of her situation. She had also lost confidence in herself, and any hope of recovering from her present status. Her routine check-up had been done by the family physician, and blood tests done, but everything was found to be normal & she was prescribed some tonics, but nothing helped. Lately, her interactions with others had reduced a lot, and she constantly talked about being a burden on everyone. The family got worried and sought help when she once tied a chunni around her neck, saying she would be better off dead as she couldn’t go on like that…

Ms S was diagnosed as severe depression. Her mother had also suffered from a similar condition, and one elder sister had to be treated for depression immediately after her child-birth. She began improving within a few weeks and by 2 months, she had almost reached her pre-morbid functioning.

Not everyone presents with such a typical picture. Not everyone seeks treatment. Most people do not recognize depression as a disease, and try to attribute the entire picture to some external events. Fewer still realize that there is help available. In fact, some may report just a part of the above picture, along with bodily complaints like pains in different parts of body, especially headaches, weakness, burning sensations in the brain, numbness, nausea, “gas”, constipation, “tension”, increased sweating, breathlessness, dryness of mouth, palpitations, “ghabrahat” or nervousness. Repeated investigations like chest X-ray, ECG, blood and urine or stool tests always turn out to be normal.

Mood disorders have been described as the commonest diseases affecting humans for nearly 2500 years, and depressive disorders affect 20% women & 12% men in their lifetime. From king Dashrath in “Ramayan” to Arjun in the “Mahabharat” and from Abraham Lincoln in U.S.A. to Winston Churchil, it spares no-one – rich or poor, in the east or west. They are a major public health problem: cause 20% suicides, a third of alcoholics to drink, high absenteeism from work and a higher disability than most chronic illnesses like diabetes, arthritis and angina. In a recent WHO-World Bank Study on Global Burden of Diseases, depression has been found to be a leading cause of disability.

More than a third of patients consulting a family physician for physical complaints actually suffer from depression. But despite its high prevalence and availability of effective treatments, it is under-diagnosed and under-treated by general physicians, & other non-psychiatric practitioners, who, paradoxically, are most likely to see these patients initially. Stigma plays a large role in patients' reluctance to seek, accept, and adhere to treatment. Yet depression can almost always be treated successfully. Thus it is necessary to increase general awareness of the public as well as of the general physicians [GPs] on this issue.

What A Gp Needs To Know About Depression :

The Disorder :

• Sad or depressed mood is a normal emotional experience in everyday life. It becomes abnormal if it becomes persistent & pervasive and accompanied by a number of other signs & symptoms.
• May manifest as a single episode, but upto 75% experience recurrences throughout life.
• Most untreated episodes last from 6 to 13 months.
• Earlier endogenous & exogenous forms used to be identified, depending upon the presence of any external causes; now largely abandoned because not every person faced with the same stressful life events becomes depressed. So if a patient meets criteria for depression, a diagnosis is made, irrespective of the precipitating factors.
• Average age of onset is 20 – 40 years, and it is twice as likely in women [due to increased stress e.g. multiple roles as homemaker, professional, wife, and mother, hormonal factors, etc.]
• There is no specific “cause” – it’s a combination of genetic and biochemical causes, psychological causes like personality type, attitudes and temperament, and social causes like death of close relatives, financial or other losses, marital discord, etc.
• Major risk factors are:
• Female gender.
• Stressful life events.
• Unemployment.
• Separated/divorced status.
• Prior suicide attempts.
• Lack of social support.
• Family history of depression.
• Current substance abuse.
• Personality attributes: lacking energy, introverted, “worriers”, dependent, hypersensitive, difficulty in coping.
• Chronic stress.
• If a “high” phase or mania occurs [i.e. a picture exactly opposite of depression, with elated mood, hyperactivity, excessive talking, spending, & energy levels, etc] or has occurred along with depression in the past, the diagnosis changes to “Bipolar Disorder” (previously called manic-depressive psychosis). Here, antidepressants alone might precipitate mania, so one must be careful in initial assessment, and treatment must include a mood stabilizer like lithium or some of the anti-convulsant drugs.
• Psychotic depressions include hallucinations or delusions which are usually logically consistent with the sad mood. E.g. a delusion that patient has sinned in an unforgivable way, or that someone is plotting to harm them and their family.

The Diagnosis

• Clinical depression is diagnosed only if mood remains sad most of the day, most days of the week, and lasts for 2 weeks or more, and there is little interest in previously pleasurable activities.
• Apart from the one of the two above mentioned essential features, there should be some of the following: markedly reduced energy levels, helplessness, hopelessness, worthlessness, loss of self-esteem, inappropriate guilt, sleep & appetite disturbances including weight loss, difficulty in thinking/concentrating, indecisiveness, absence of normal emotional responses to events or activities, a feeling of impending doom, marked slowness in thinking or actions (remarked by other people), lack of initiative, marked loss of desire for sex, inability to describe their feelings etc., sometimes specially worse in the mornings. In severe cases, there is a death-wish, suicidal ideation, planning or even attempts.
• Anxiety symptoms commonly co-occur.

The Treatment :

Objectives include symptom removal, restoration of functioning, and prevention of relapses/recurrences. The questions often faced are:

• Where to treat (OPD or admission) ?
• Types of treatment available ?
• When to treat and when to refer ?
• Where: depends on the capacity of patient to recognize and follow instructions, level of social resources, stressors, level of functional impairment and imminent risk of suicide. Except for the last, most cases can be treated on an out-patient basis.
• Common treatment modalities available are :
  Drugs : all available antidepressants are similar in overall efficacy, speed of response, and long-term effectiveness; they differ only in their drug-drug interactions and side-effects, most of which are dose-dependent. So the golden rule is “start low and go slow.” For most patients, the benefits of treatment far outweigh the risks. One needs to remember that there’s almost always a lag period of upto 2 – 3 weeks even for response to start.

The major groups of drugs available today are as follows:

Older drugs like tricyclics are now reserved for some cases of severe depression or for those who may already be on them. The common side-effects are constipation, dryness of mouth, blurring of vision, tremors, sedation etc. These usually improve with time.

The newer drugs are safer and have much fewer side-effects, mainly nausea and sometimes sexual dysfunction. fluoxetine & sertraline are the most commonly used ones, the others must be used only after familiarizing oneself with details of their specific advantages & disadvantages.

• Psychotherapy : this includes explaining the diagnosis, treatment plan & expected duration of therapy, & counseling about adverse effects of drugs. Some formal and specialized therapies are also available & often used in combination with drugs for best results. It greatly improves targeted difficulties (e.g. marital counseling & interpersonal therapy improves relationships, relaxation therapy helps anxiety symptoms, etc). Also, it lacks side effects, may be effective for some patients for whom medications are not effective, & may make depression less likely to recur once treatment stops because patients learn to cope with or avoid factors contributing to recurrence.
• Electro-Convulsive Therapy [ECT] : this is a highly maligned form of treatment, largely due to myths and misconceptions surrounding it, largely due to misrepresentation by the media and films.
  It has proven efficacy in the severely ill (suicidal or psychotic), those who have failed to respond to medication trials, who have serious general medical conditions, or during the 1st trimester of pregnancy. There is more rapid resolution of life-threatening features than medication, and so it can be life-saving for some. It is scientific, does not cause any brain damage, but should be used only by qualified psychiatrists.
• Combination of Medication and Psychotherapy : this may be specifically useful when either treatment alone is only partially effective, or clinical circumstances suggest two discrete targets of therapy (e.g., symptom reduction addressed by medication and psychological/social/ occupational problems addressed by psychotherapy).

When to refer :

It would be ideal to refer every patient with suspected depressive disorder to a psychiatrist for a thorough assessment and initiation of appropriate treatment. Later, the patient should follow-up with the GP, who can continue with further management like providing support, advice, reassurance, and hope, as well as monitor side-effects and dosage adjustments.Patience is required since side-effects often appear before the beneficial effects, which may take 2 weeks or more. Compliance is important because skipping doses when feeling better can not only undo all the good, but make the patient feel worse due to withdrawal symptoms.

Also, lower doses can be ineffective and higher doses dangerous. So, the professional advice should be strictly followed. The duration of treatment must be decided in each case by the psychiatrist, and in some cases of recurrent depression, life-long therapy may be indicated to avoid recurrences.

Also, family members must be educated about the illness, need for treatment and providing constant support and encouragement to the patient. This "clinical management" is exceptionally important, because the pessimism, low motivation and energy, and sense of social isolation or guilt of the depressed may lead them to give up, not adhere to treatment, or even to drop out of treatment.

Other important issues :

• Generally, about 45 – 60 % patients respond.
• Treatment is more effective earlier in the episode, before it becomes chronic.
• Benzodiazepines like alprazolam, diazepam, lorazepam, nitrazepam must be used only initially, and never as the only treatment. They should be used judiciously, in low doses, and under careful supervision due to the liability of dependence and withdrawal symptoms.

Common Problems Faced By GPs :

• Mistaking depressive symptoms or adjustment disorder for depressive disorder leading to unnecessary treatment.
• Mistaking depressive disorder for depressive symptoms / adjustment disorder leading to missed treatment.
• Mistaking bipolar disorder or recurrent depression for unipolar depression due to lack of information & inadequate history taking leading to switches to mania, rapid cycling between depression & mania, under-treatment, frequent relapses & chronicity.
• Mistaking psychotic depression for schizophrenia.
• Lack of information about course & outcome leading to under-treatment.