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May 2012 |
Depression is thought to be undoubtedly the most common single entity that brings a patient into the physician’s office. The symptom itself is rarely presented directly, because the patient is generally not aware that he/she is depressed. By far the most likely complaints are those of a physical nature—fatigue, weakness, non-specific pain, lack of interest, sleep disturbance, or weight changes. Depressive disorder is a global health problem and reflects an experience that is a consequence of a painful, subjective mood state characterized by feelings of sadness, discouragement, loneliness, worthlessness and isolation. It is frequently manifested by unwarranted crying spells, sluggishness of mental and physical activity and suicidal thoughts. Sleep, energy and appetite are often affected, as well as sexual drive and desire. Sex, sleep and appetite can be affected in either direction and may be severely diminished or irrationally increased, but energy is generally decreased. Perhaps it can best be described as emotional pain accompanying a sense of sadness that seems to be far greater than the context or circumstance in which it occurs. This pain disrupts and profoundly affects the sufferer’s view of the value of life and traumatizes those who are closely involved with them. As described by Andrew Solomon in his award-winning memoir of a depressive illness, it is a sense of unspeakable despair that cannot be expressed much less shared. William Stryon agreed, stating that its horror is quite beyond expression. Its only saving grace, Stryon adds, is that it is conquerable; if it were not then suicide would be the only remedy. It has been suggested that depression causes more disability than other chronic illnesses such as diabetes mellitus, arthritis and angina; primarily because only 30% of those afflicted receive treatment and therefore its chronicity and complications affect both the sufferer and their social networks. This sense that it is under-recognised, even by those who suffer it, naturally extends itself to a situation where it will be under-diagnosed by those who may be called upon to treat it. It has been described as the archetypal modern disease and straddles an unstable bridge between social conditions and brain biochemistry. This makes it difficult for both patients and clinicians to confront its presence with great certainty because sadness is a natural and normal part of the human condition, the precise point at which it becomes pathological and necessitates professional intervention is sometimes unclear. Some argue that in the attempts to make it more recognizable and visible, it may be reaching a point where it is being sought too aggressively and will ultimately result in it being over-diagnosed as has happened with other conditions such as Attention Deficit Hyperactivity Disorder (ADHD). The danger here is that individuals may begin to feel that all sadness and indeed any suffering is pathological and requires either medication or therapy. How is normal sadness separated from pathological depression? CLASSIFICATION AND DIAGNOSTIC CRITERIA – DSM-IV According to the classification system of the American Psychiatric Association’s (APA) Diagnostic and Statistical Manual which is now in its fourth revision and called DSM-IV-TR (TR refers to Text Revision), it can be divided into three groups, major depressive disorder, dysthymia and depressive disorder not otherwise specified. The latter is a catch-all for premenstrual dysphoria (PMS—irritable and unhappy mood), minor depressive episodes and recurrent brief depressive episodes. These three categories of depression represent the general diagnostic criteria and include within their headings many subtypes. The following criteria established by the APA for the diagnosis and classification of depression represent the criteria most used by mental health professionals to diagnose the disorder. An alternative classification, the International Classification of Diseases (ICD-10), is produced by the World Health Organisation and is now fairly consistent with the DSM system. Major depressive episode: five or more of the following symptoms present for most of two weeks and representing a change from previous functioning. The essential but not sufficient symptoms that must be present are 1 and/or 2, that is, a depressed mood and/or a marked loss of interest or pleasure. The symptoms are:
These symptoms must cause significant distress, must not be due to the physiological effects of a medical disorder or substance use and are not better accounted for by bereavement. Mild major depressive episodes suggest meeting the minimum criteria and causing relatively less functional impairment. Moderate depressive episodes have more functional impairment and more symptoms than meet the minimum criteria while severe episodes cause such marked impairment that functioning is almost totally impaired, with problems of self care, marked reduction of daily activity inclusive of eating and attending to basic needs and constantly significant suicidal and/or homicidal ideation. For dysthymia, the person must have a depressed mood for most days over at least a two-year period (one year for children and adolescents). The symptoms would never have been absent for more than two months, and no major depressive episode would have occurred within the first two years of the disorder. There must also be at least two of the following symptoms:
Patients with dysthymia can have superimposed major depression and are then described as having double depression. In psychotic depression, the patient has a severe mental disorganization, with some degree of loss of contact with reality. In melancholic depression, there are marked somatic or physical symptoms. Depression can also be part of a manic depressive illness or bipolar disorder; in this case it is called bipolar depression. History-taking should always include questions about mood swings, previous manic symptoms, for instance, over-activity, grandiosity, impulsiveness, excessive and inappropriate spending or sexual activity, talkativeness, easy distractibility, a subjective feeling that one’s thoughts are racing beyond control. This would establish the presence of bipolar disorder rather than unipolar depression. Other categories of depression include Mixed Anxiety and Depressive Disorder where it is difficult to distinguish the temporal relationship between disabling anxiety and depressive symptoms and Adjustment Disorder with depressed mood where in response to a life stressor, the individual experiences periods of depressed mood but does not fulfil the other criteria for a Major Depressive Episode. Depression may also present in atypical ways at both extremes of the age spectrum. In the elderly, it may present as a syndrome of decreased motivation with a lack of mental flexibility and mild cognitive deficits. In the adolescent, it may present with disruptive behaviour, substance abuse and self harm before the low mood is actually evident. In may also occur in the post partum period with an onset two to six weeks after delivery. The risk here is self neglect by the mother and neglect of the newborn baby with infanticide as a possible outcome. Mood disorders contribute to an increased consumption of health care because many people do not understand what they are experiencing and frequently respond by seeking medical help before mental health help. Patients with bipolar disorder for example have been calculated to consume four times more health care than those with unipolar major depression. Depression whether of the unipolar or bipolar variety is also the psychiatric disorder that is most associated with suicide and more recently with homicide, making it the most potentially lethal mental illness. It has also been reported that people with depression tend to experience more physical pain symptoms than people who are not depressed or would have more painful exacerbations of existing illness. It leads to more inappropriate use of hospital beds, a greater risk of hospitalization for physical illness and prolongs periods of hospitalization. It is also associated with reduced compliance to medical treatments and is an independent predictor of increased mortality for physical illness. This further increases the risk that depression will present to the general practitioner and would therefore be initially managed outside of the mental health services. In addition, when the experience is one of dysthymia, which is a mild but chronic depression, many people think it is the way their life has been and will continue to be. This sense however undermines and disables them even as they are able to continue struggling to function and fulfil their daily commitments. Major depression is a more acute phenomenon that demonstrably causes impairment and sometimes complete breakdown. People with depression are therefore more likely to utilize health services and the cost to society of this condition through health care utilization alone is tremendous, in addition to the social, family and community costs. There is no doubt that when the disorder does exist, it is a source of great suffering and disability and contributes to mortality through suicide, particularly in the young adult and elderly age groups. This explains why depression is estimated to become the second highest cause of disability by 2020. Only about 40% of patients with depression receive treatment and not all of those receive the appropriate treatment while roughly half of the people with depression never seek any help at all from any source. The value of successful intervention for depression will mean diminished morbidity for a range of medical conditions, decreases in the suicide, violence and homicide rates and more effective utilization of health services. There will also be greater productivity in the society through the reduction of social pathology, improvements in functional performance and improved time utilization for the people whose lives are entwined with those who suffer through the experience of having depressive disorders. This is the fifth of a six-part series on mental health issues by Professor of Psychiatry, Gerard Hutchinson. Professor Hutchinson is the head of Department, Clinical Medical Sciences, School of Medicine, Faculty of Medical Sciences, EWMSC, UWI. Next: Violence |
