Depression is one of the common problems in clinical practice, which causes social, occupational, financial, and interpersonal difficulties. It also causes increased medical morbidity and mortality through suicide. Most of the subjects suffering from depression first go to their general physicians or family physicians. However, most physicians are very busy and preoccupied with general medical problems. Moreover, the general physician is not well acquainted with psychiatric problems. The difficulty is further compounded since a number of medical illnesses may cause either secondary or reactive depression.
Further, the medical treatment of number of physical illnesses causes depression as a complication. These many facets of depression are likely to pose a clinical problem or challenge to the physicians.
What is depression?
Depression is a normal emotion. In certain situations or circumstances, it becomes either unbearable or problematic. All people at some time or other experience low mood, low spirits, disinterest or disgust. The word depression has been interchangeably used to describe a symptom, a syndrome, and a disease in the classical meanings of those words.
Epidemiology of depression:
How common is depression?
Depression is the commonest form of psychiatric disorders. This is the commonest psychiatric problem, a general physician faces. It is also the commonest disorder, which is likely to be frequently missed, go undetected, or maltreated. Often, major psychotic disorders like schizophrenia are recognized easier than depression.
A clinic ? based study shows presence of depression from 6% to 35% in India.
Males to female ratio are 1:2.
While morbidity is higher in women, mortality in the form of suicide is greater in men. Suicidal attempts are higher in women.
Incidence of depression is higher in middle age, but it can be seen in any age.
Other demographic variations
* More common in North India than South.
* Certain casts.
* Males living in joint families.
* Middle age- 35 to 54 years in males and 15 to 34 years in females.
* Lower socio-economic group.
Causes of depression
Depression is a multifactorial disorder. Most frequent causes are-
Some clear-cut evidences have been found that some hereditary factors are responsible for depression. Alcoholism, drug abuse, suicide or antisocial activities predispose to depression.
These are very easily acknowledged in some cases. Environment can affect in these two ways-
Internal environment: intercurrent or chronic illness or medications, which may cause depression.
External environment: uneasy climate.
Life events are important changes occurring in individual?s life, which produce stress and reacquire adaptability from the individual. Positive and negative social experiences are responsible for depression.
Biological reactions of the individual certainly play role in depression.
Clinical features of depression
* Sadness of mood is likely to be a symptom of depression, when severe may be accompanied by a desire to weep or crying spells.
* Inability to enjoy or derive pleasure from usual activities which gave pleasure earlier.
* Lack of interest in day to day activities.
* Bad thoughts about self, about family and also about the future.
* Self-blame, self-criticism and guilt.
What are the symptoms of depression?
* Affective or mood symptoms.
* Cognitive or thought symptoms.
* Behavioral symptoms.
* Physical or somatic symptoms.
* Biological symptoms.
* Psychotic symptoms.
Affective or mood symptoms
* Dejected and sad mood.
* Negative feelings towards self.
* Reduction in enjoyment.
* Loss of emotional attachment.
* Weeping and crying spells.
Normal sadness is not persistent while depression is persistent.
Cognitive or thought symptoms
* Low self-evaluation.
* Negative expectations- pessimism, hopelessness.
* Self-blame and self- criticism, guilt.
* Disturbances of body image.
* Motivational manifestations like-
? Paralysis of the will.
? Avoidance, escapist and withdrawal wishes.
? Suicidal wishes.
? Increased dependency.
* Slowed down.
* Psychomotor retardation.
* Poor personal hygiene.
* Some times restless, agitated, anxious and nervous.
Physical or somatic complaints
* Most depressed persons consult the physician basically for physical problems.
* Multiple aches and pains.
* Easy fatigability, lethargy and tiredness.
* Weak and run- down.
* Tingling, numbness and prosthesis.
* Loss of appetite.
* Sleeplessness or rarely sleepiness.
* Loss of libido.
* Delusions of somatic symptoms.
* Delusions of poverty.
* Delusions of crime and punishment.
* Hallucinations of hearing voices, visions etc.
(Auditory hallucinations are not persistent in depression but persistent in schizophrenia)
What are the signs of depression?
* Sad faces.
* Stooped posture.
* Motor retardation or agitation.
* Smiling faces in smiling depression.
* Retarded speech.
* Delay in answering and gap between phrases and sentences.
* Voice may die in last of sentence and often-monotonous tone.
* Slowing of movements.
* Low work out put and efficacy.
* Depressive stupor.
* Sometimes hyperactivity.
* Dryness of mucosae and skin, with constipation.
* Poor concentration, poor memory etc.
Types of depression
? Primary – arise of themselves.
? Secondary – follows in train of some illness or event.
Other criteria to determine the types of depression:
? Endogenous and reactive
? Psychotic and neurotic
Endogenous depression is similar to primary and reactive to secondary depression.
* Non psychotic.
* Reactive to a situation.
* No endogenous symptoms like loss of weight, appetite, guilt, diurnal variations etc.
* Long term.
* Due to unconscious conflict not easily identified.
* Associated with other neuroses like anxiety, obsessions, conversions or hypochondriasis.
The term often used for depression with physical symptoms.
It is due to maladaptive reaction to an identifiable life event or circumstance, known as stressor. The stressor may be single, such as an uncomplicated divorce, or multiple, such as death of a beloved one occurring at a time of marked business difficulties and physical illness. They may be recurrent such as frequent crop failures or continuous, such as chronic illness or living in a poverty area.
Chronic depressive disorder
Characterized by a chronic (at least two years) non-psychotic disturbance of depression.
Symptomatic depressive disorders
Functional symptoms developing as a result of organic brain disease. It often occurs in people who are unaware that they are physically ill.
* After cerebro-vascular accident (post stroke depression).
* With left anterior lesions (especially left frontal cortex and left basal ganglia).
* Subcortical atrophy.
* Left and right hemisphere lesions.
q Organic mood syndrome.
Depression and endocrines are very closely related with each other.
Anxiety is prominent in hyperthyroidism (persistent anxiety or apathetic thyrotoxicosis), pheochromocytoma (episodic anxiety), and hypoglycaemia due to an insulinoma. Depression is common in hypothyroidism, Cushing?s syndrome, Addison?s disease and hyperparathyroidism.
Depression in cancer
Some studies show that depression precedes manifestation of tumor in several cases e.g. marked depression preceding pancreatic carcinoma, which is very difficult to diagnose at earlier stage.
Depression is common before-
* Primary or secondary cerebral tumor.
* Subacute diffuse encephalopathy.
* Lung carcinoma, which secretes ectopic ACTH leading to Cushing?s syndrome or hyperparathyroidism, like symptoms.
This appearance of depression is because of effects of the peptide substances secreted by tumor on the nervous system.
Neuropsychiatric features in the patients of following diseases are well recognized:
* Systemic lupus erythematosus.
* Rheumatoid arthritis.
* Polyarteritis nodosa.
* Temporal arteritis.
Drug induced depression
These may be divided as follows:
* Behavioral toxicity- irritability, aggression, hostility and hypersexuality.
* Delirium- acute confusional state.
* Depressive reactions- mild to severe psychotic depression.
* Paranoid and schizophrenia- delusions of persecution and thought disorders.
* Hallucinations- usually visual.
* Dementia and pseudodementia- cognitive changes, reversible or irreversible.
* Neuropsychiatric states- ataxia, dysarthria or convulsions.
The common drugs responsible for depression are-
? Major tranquilizers.
? Stimulants during withdrawal.
Clinical assessment of depression
* Type of onset.
* Level of depressed mood.
* Change in behavior-
? Slowing of thoughts, speech or movements.
? Sleep changes.
? Diurnal variation of mood.
? Loss of appetite.
? Weight loss.
? Loss of general interest and sex.
? Guilt, overvalued and delusions.
* Presence and severity of anxiety.
* Presence and severity of agitation.
* Presence of delusions and hallucinations.
* Dangerousness (suicide, homicide, infanticide, self-neglect).
* Effect of medical conditions on mood.
* Use of drugs and alcohol.
* Full blood counts, ESR, blood urea and electrolytes, sugar, cholesterol, vitamin 12.
* T3, T4, THS.
* Sexual function.
* Other relationships.
* Other activities.
After patient?s permission, inquiry with patient?s relatives and friends gives precious information and helps in diagnosis of depression.
? Dr. Rajneesh Kumar Sharma
Homoeo Cure & Research Centre P. Ltd.
N.H. 74, Moradabad Road,
Kashipur- Zip- 244713
Ph. 05947- 260327, 274338, 277418, 275535
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