Depression

Overview of Depression:

It is a condition that causes extremely low also sad mood, that can last for weeks, months or even years. Everyone at some point in their lives, feels sad, low and dejected, but when this sadness begins to infiltrate into a person’s behaviour, relationships and work, it called Depression and requires the help of trained medical professional.

Epidemiology of Depression

Causes of Depression 

It’s not known exactly what causes depression. As with many mental disorders, a variety of factors may be involved, such as:

Biological differences

People with depression appear to have physical changes in their brains. The significance of these changes is still uncertain, but may eventually help pinpoint causes.

Brain chemistry:

Neurotransmitters are naturally occurring brain chemicals that likely play a role in depression. Recent research indicates that changes in the function and effect of these neurotransmitters and how they interact with neurocircuits involved in maintaining mood stability may play a significant role in depression and its treatment.

Hormones:

Changes in the body’s balance of hormones may be involved in causing or triggering depression. Hormone changes can result with pregnancy and during the weeks or months after delivery (postpartum) and from thyroid problems, menopause or a number of other conditions.

Inherited traits:

Depression is more common in people whose blood relatives also have this condition. Researchers are trying to find genes that may be involved in causing this disease.

Risk Factors of Depression 

This disease is one of the most common mental disorders in the U.S. Current research suggests that this disease is caused by a combination of genetic, biological, environmental, and psychological factors.

• This disease can happen at any age, but often begins in adulthood.
• This disease is now recognized as occurring in children and adolescents, although it sometimes presents with more prominent irritability than low mood.
• Many chronic mood and anxiety disorders in adults begin as high levels of anxiety in children.
• Risk factors include:

• Personal or family history of depression.
• Major life changes, trauma, or stress.
• Certain physical illnesses and medications.

Types of Depression

Major Depression i.e.:

• • Symptoms should be constant everyday for at least 2 weeks.
  • Down the black hole’ is the constant feeling.

Atypical Depression i.e.:

• • • People with this type of disorder have associated bad experience in childhood.
    • Both physical and emotional symptoms are associated.

Chronic Depression i.e.:

• • • • It is mild, less severe and chronic.
      • It can be periodic, occurring at fixed intervals of time.
      • Genetic factor can be associated.

Bi-polar Depression i.e.:

• • Depression occurs in alternation with periods of mania, wherein the individual feels unusually ecstatic, hyper and aggressive.

Seasonal Depression i.e.:

• • It happens every year at the same time.
  • Usually it is seen at onset of summers or winters.

Other Types i.e.:

Symptoms caused by major depression can vary from person to person. To clarify the type of depression you have, your doctor may add one or more specifier. A specifier means that you have depression with specific features, such as:

Anxious distress —

depression with unusual restlessness or worry about possible events or loss of control

Mixed features —

simultaneous depression and mania, which includes elevated self-esteem, talking too much and increased energy

Melancholic features —

severe depression with lack of response to something that used to bring pleasure and associated with early morning awakening, worsened mood in the morning, major changes in appetite, and feelings of guilt, agitation or sluggishness.

Atypical features —

depression that includes the ability to be cheered by happy events, increased appetite, excessive need for sleep, sensitivity to rejection, and a heavy feeling in arms or legs.

Psychotic features —

depression accompanied by delusions or hallucinations, which may involve personal inadequacy or other negative themes.

Catatonia —

depression that includes motor activity that involves either uncontrollable and purposeless movement or fixed and inflexible posture.

Peripartum onset —

depression that occurs during pregnancy or in the weeks or months after delivery (postpartum).

Seasonal pattern —

depression related to changes in seasons and reduced exposure to sunlight.

Pathophysiology of Depression

The exact pathogenesis of major depressive disorder is not completely understood; however, following etiologies have been suggested to play a role in the development of major depressive disorder.

1. Neurotransmitters

Serotonin: Serotonin depletion has been most commonly shown to be associated with depression.  For this reason, serotonergic agents are first-line treatment of major clinical depression.

Norepinephrine: Abnormal norepinephrine metabolites have been shown in blood, urine, and CSF in patients with major depressive disorder. Serotonin-norepinephrine reuptake inhibitors (e.g., venlafaxine) increase both serotonin and norepinephrine levels and are used as the firs-line treatment of major depressive disorder.

Dopamine: Major depressive disorder may be associated with decreased dopaminergic activity. It has been suggested that patients with major depressive disorder may have dysfunctional masolimbic dopamine pathway and/or hypoactive dopamine D1 receptors. Reduced dopamine concentrations with drugs (e.g. reserpine) or certain pathologic conditions (e.g. Parkinson’s disease) have been linked to symptoms of depression. In addition, drus increasing dopamine concentrations, such as amphetamine, bupropion, and tyrosine can reduce depressive symptoms.

2. Psychosocial

3. Cognitive:

Cognitive theory of Aaron Beck describes a triad of 1) negative self-view 2) negative interpretation of experience and 3) negative view of future.

4. Learned helplessness:

Based on this theory, depression is linked to an individual’s inability to control events.

5. Stressful life events:

Stressful life events may result in permanent neuronal alterations, subsequently predisposing an individual to mood disorders. The most often associated life event linked to the development of depression is losing a parent before age 11. (1)

Clinical Features of Depression

Basically, Depression is a mood disorder that causes a persistent feeling of sadness and loss of interest. Also called major depressive disorder or clinical depression, it affects how you feel, think and behave additionally, it can lead to a variety of emotional and physical problems. Besides this, you may have trouble doing normal day-to-day activities, also sometimes you may feel as if life isn’t worth living.

Signs and Symptoms:

If you have been experiencing some of the following signs and symptoms most of the day, nearly every day, for at least two weeks, you may be suffering from depression:

• Persistent sad, anxious, or “empty” mood.
• Feelings of hopelessness, or pessimism.
• Irritability.
• Feelings of guilt, worthlessness, or helplessness.
• Loss of interest or pleasure in hobbies also activities.
• Decreased energy or fatigue.
• Moving or talking more slowly.
• Feeling restless or having trouble sitting still.
• Difficulty concentrating, remembering, or making decisions.
• Difficulty sleeping, early-morning awakening, or oversleeping.
• Appetite also weight changes.
• Thoughts of death or suicide, or suicide attempts.
• Aches or pains, headaches, cramps, or digestive problems without a clear physical cause also that do not ease even with treatment.

Sign & Symptoms of Depression 

Mental Symptoms:

Though these symptoms vary from person to person, there are few common mental symptoms.

Physical Symptoms:

Mental stress can channelize into symptoms of the body such as;

• Overwhelming fatigue also exhaustion.
• Weight loss or gain.
• Unrefreshing sleep with either drowsiness or sleeplessness.
• Disinterest in sex with decrease in sex drive.
• Either weight gain or weight loss.
• Lethargy also intense fatigue.
• Bodyache.
• Headaches.
• Either Insomnia or excessive sleep.
• Lack of interest in sex.
• Abuse or misuse of alcohol, drugs, etc.

Clinical examination

Physical examination of patients with major depressive disorder is usually normal. A mental status examination may provide valuable information in patients with major depressive disorder.

• General appearance:
  • Psychomotor agitation or retardation
  • Poor eye contact
  • Tearful
  • Inattentive to personal appearance
• Affect:
  • Constricted or labile
• Mood:
  • Depressed
  • Irritable
  • Frustrated
  • Sad
• Speech:
  • Little or no spontaneity
  • Monosyllabic
  • Long pauses
  • Soft, low monotone
• Thought content:
  • Suicidal ideation
  • Obsessive rumination
  • Pervasive feelings of hopelessness, helplessness, worthlessness, guilt
  • Somatic preoccupation
  • Indecisiveness
  • Poverty of through content
  • Mood-congruent hallucinations and delusions
• Cognition:
  • Distractile
  • Difficulty concentrating
  • Poor memory
  • Apparent disorientation
  • Impaired abstract thinking
• Insight and judgment:
  • Impaired (1)

These exams and tests can help rule out other problems that could be causing your symptoms, pinpoint a diagnosis and check for any related complications:

• Physical examination: Generally, Your doctor may do a physical exam and ask questions about your health. In some cases, this disease may be linked to an underlying physical health problem.
• Lab tests: For example, your doctor may do a blood test called a complete blood count or test your thyroid to make sure it’s functioning properly.
• Psychological evaluation: Expect your doctor or mental health provider to ask about your symptoms, thoughts, feelings and behavior patterns. You may be asked to fill out a questionnaire to help answer these questions.

DSM-5. Your mental health professional may use the criteria for this disease listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), published by the American Psychiatric Association. All in all, this manual is used by mental health providers to diagnose mental conditions and by insurance companies to reimburse for treatment.

Differential diagnosis 

• Bipolar disorder
• Borderline personality disorder
• Adjustment disorder with depressed mood
• Anxiety
• Drug induced mood disorder
• Obsessive compulsive disorder
• Organic (3)

Complications 

What can Depression lead to ?

In general, It is a misconception that Depression is a short-lived state of the mind that goes away easily. But Depression  touted to be amongst the major killers today because of its adverse complications on the depressed individual.
If untreated, It can lead to;

1. Self-hatred
2. Substance abuse
3. Physical illnesses like Eating disorders, Sleeping disorders, etc.
4. Unemployment
5. Suicide

Investigation

• There are no diagnostic laboratory findings associated with major depressive disorder.
• Dexamethasone suppression test:
  • About 50% of patients with major depressive disorder have abnormal dexamethasone suppression test. Nonsuppression (positive test result) shows cortisol hypersecretion secondary to a hyperactive hypothalamus-pituitary-adrenal axis.
  • However, dexamethasone suppression test is not routinely used in the diagnosis of major depressive disorders due to high rates of false positives and false negatives.
• Diminished TSH in response to TRH and decreased prolactin release in response to tryptophan have been reported in patients with major depression. However, the results are not definitive, and thus, are not used routinely used in clinical practice. (1)

Treatment of Clinical Features

Cognitive Behavioral Therapy

Cognitive Behavioral Therapy is a short-term therapy usually lasting between six to 12 weeks. A therapist helps people who are sad or scared. They help them learn how their thoughts, feelings, and thinking are related to making them feel better. It is like when you get hurt and your mom tells you not to do it again. A therapist will tell kids they need to be more careful next time they play with the fire. CBT teaches problem-solving skills so that people can feel better now and cope with their feelings.

Psychotherapy

Psychotherapy is a short-term, goal-oriented psychotherapy that gives people tools to deal with problems in life. A therapist helps you talk about what is on your mind, so you don’t feel bad. It teaches emotional coping skills instead of emotional expression or catharsis.

Talk Therapy

Talking therapy is a way to help people who are feeling bad or have hard times. They get support from other people while talking about their feelings. This may be done with one person, called individual therapy, or it may be done as a group. Group talk therapy can help people learn how to deal with stress and feel better about themselves by sharing their experiences with others.

Dialectical Behavioral Therapy DBT

Dialectical Behavioral Therapy helps people learn how to manage their emotions and change the way they think. It teaches people how to deal with stress and emotional problems. It is like a skill that helps you make good relationships.

TMS Therapy

TMS stands for Transcranial Magnetic Stimulation. This is a form of therapy that uses magnets to help treat depression. Also, studies have shown that it is the same as brain stimulation treatments like electroconvulsive therapy (ECT).

Electroshock Therapy

ECT is a kind of therapy that doctors do for people who are very sad or who have bipolar disorder. Doctors put electrodes on the head, and then they send an electric current through the brain. Doctors may prescribe electroconvulsive therapy as a last-resort treatment. This is when an antidepressant medication doesn’t work, or if it does but symptoms do not go away quickly. Also, it can help with symptoms like anxiety and depression, and people who are at risk of suicide.

Medication :

There are many medications available today which help treat depression symptoms in patients. Some of these medications are antidepressants, anti-anxiety drugs, mood stabilizers, and antipsychotics.

Lifestyle Changes

A doctor might also recommend lifestyle changes like exercise and getting enough sleep. If you wake up, make sure to get outside for at least 30 minutes a day. Also, try not to eat too much sugar or drink caffeine after lunchtime. Other changes are:

Exercise

Try to exercise for at least 30 minutes a day. Try to do this every day of the week, even on weekends. Exercise can help you feel less depressed and anxious. It can improve your mood and make you feel more energetic. It can also help you sleep better at night.

Sleep

Doctors recommend that people get at least eight hours of sleep every night. During the first few weeks, try to go to bed an hour earlier than usual until it becomes a habit. People who are depressed often wake up early in the morning because they find it difficult to fall back to sleep. If you wake up, try not to go back to sleep right away but do something else like reading a book or surfing the Internet.

Social Support

Doctors also recommend getting social support. This means being with the people you love or having fun activities to do. For example, try spending time doing anything that makes you feel calm and relaxed like reading a book or listening to music.

Nutrition

Eating a healthy diet can help treat depression. This means eating more fresh vegetables, fruits, and whole grains. Avoid foods that have too much sugar or caffeine in them like chocolate or soda pop. It also helps to drink at least eight glasses of water every day so you don’t get dehydrated from not drinking enough fluids.

Stress Reduction

Doctors recommend that people reduce stress in their lives. This means taking care of yourself. For example, avoid arguments and traffic jams. Take care of yourself when you are sick.(2)

Prevention

Stress Management

Depression has been linked to the destabilizing effects of an adverse, traumatic life event. While this difficult experience often occurs early on and during childhood, depression can stem at any point in life. As a result, learning how to manage the stressors in one’s life—and teaching one’s children how to do so—can have a protective effect against different mental health issues, particularly depression and anxiety. Stress management refers to the ability to respond to stressors in a more considered manner, instead of being driven by automatic responses that may add to their distress. Turning to loved ones for support, and reaching out to mental health professionals, as well as treatments such as Deep TMS™, which have been recognized for their safety and efficacy, build a more adaptable response system to unexpected or upsetting elements.

Protecting Against Repeated Episodes

Depression can repeat itself, haunting the individual after the initial depressive episode has passed. The thought of a returning bout of depression can bring on fear, frustration, and hopelessness that the condition will ever truly disappear. But it can also help the patient gain a better understanding of what tends to trigger their depression, in an effort to change the way they approach such experiences.

Though daunting, developing greater awareness of the underlying issues of one’s depression can help work through the pain and trauma that may have contributed to its appearance. It can also promote the individual’s ability to avoid diving into another depressive episode, by relying on support methods and circles that have already proven to be instrumental in promoting their exit from previous depressive episodes.

Leading a Healthy Lifestyle

Nutrition and exercise have been found to protect against the appearance of mental health disorders, such as depression.

Nutrition

Consuming a Mediterranean diet consisting of whole grains, olive oil, fruit, vegetables, fish, low fat dairy products, and antioxidants, has repeatedly been found to lead to a 32% reduction in the risk of developing depression. Raw nuts and legumes have similarly been associated with depression symptom alleviation.

Antioxidant and anti-inflammatory-rich diets have also been linked to lower risk of depression. A possible explanation for this is their beneficial effects on gut health, which has been established to hold a link to brain functioning.

On the other hand, adhering to a Western diet, composed of a high intake of processed and red meat, refined grains, candy, high-fat dairy products, and potatoes, has been linked to an increased chance of developing depression. Higher percentages of saturated fats and sugars—considered Western diet staples—were found to be associated with a higher risk of developing anxiety.

Dietary supplements have shown protective benefits, as well. Specifically, the absence of sufficient levels of vitamins D, B6 and B12, in addition to zinc, folate acid, and iron have been found to be associated with increased levels of depression.

Exercise

Exercise similarly affects one’s mental health, by increasing their level of endorphins, which are mood regulators. Research has specifically shown that low-intensity aerobic exercise, carried out for 30-35 minutes a day and 3-5 times a week, is a reliable mood regulating activity.(4)

Diet & Regimen

• Eat diet with antioxidant
• Eat selenium rich diet
• Do regular physical exercise
• Avoid alcohol and drug
• Get enough vit D
• Meditation

Do’s & Don’ts

Reference of Depression

1. Major depressive disorder pathophysiology – wikidoc
2. Depression Treatment: Effective Ways to Treat Depression (mantracare.org)
3. What are the Differential Diagnoses for Depression? (psychscenehub.com)
4. Prevention of Depression – Can You Prevent Depression? (brainsway.com)
5. (Depression and Other Common Mental Disorders – Global Health Estimates, 2017).
6. National Mental Health Survey (NMHS) 2015-16.
7. Mind Voyage.

8. Undoing Depression (Revised Edition),Author: Richard O’Connor, PhD, (2016),Publisher: Little, Brown Spark

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