Helix Health

Depression

One out of three people will experience depression at some point in their lives, making it a very common condition. About 1 out of 10 will meet the diagnostic criteria and are diagnosed with clinical depression. Depression tends to be mild to moderate and 75% of those that are depressed, do not meet all the criteria for a medical diagnosis. Clinical depression excludes depression due to substance abuse and depression due to a general medical conditions. Inclusion of these would raise these statistics even further.

Depression can be a single episode, recurrent or chronic. A single episode is signified by the presence of clinical depression on one occasion only. Recurrent depression is characterised by episodes of depression with periods of normal functioning occurring in between episodes. Chronic depression occurs when a single episode continues for more than two years.

Symptoms

Depression is characterised by the presence of a depressed mood or lost of interest and pleasure in daily activities for at least two weeks. Although a depressed mood caused by either substance abuse or a general medical condition is not medically considered to be an occurrence of clinical depression, symptom alleviated with complimentary medicine in these instances can still be beneficial .Symptoms vary in degree of severity and present in different combinations, including the following:

Emotions and Mood:

• Depressed mood most of the day, nearly every day
• Anhedonia: Diminished interest or pleasure in all, or mostly all activities for most of the day, nearly every day
• Egocentrism or self-centredness
• Feelings of worthlessness, excessive guilt, hopelessness, isolation/loneliness and/or anxiety, nearly every day
• Feelings of overwhelming sadness, fear or emptiness, or fear of abandonment by loved ones
• Recurrent thoughts of death or suicide, suicidal ideation or suicide attempt(s).

Cognitive symptoms

• Diminished capacity to think or concentrate, nearly every day
• Difficulty making decisions, nearly every day
• Slowing down of cognition, including memory

Physical Symptoms

• Significant weight loss or weight gain (a change of >5% of body weight per month)
• Increased or decreased appetite nearly every day
• Insomnia or hypersomnia nearly every day
• Psychomotor agitation or retardation nearly every day, producing states of over or under activity.
• Fatigue or loss of energy nearly every day

Behavioural Symptoms

• General slowing down in activities and speed
• Avoidant behaviour leading to social isolation
• Decrease in daily activities, including household tasks and work responsibilities
• Neglect of personal hygiene

DSM IV Diagnostic Criteria

Major depression (also known as clinical depression) is defined first and foremost by the presence of five or more of the following symptoms, which should be present for a period of at least two weeks and signifies a change from previous functioning. Symptoms should cause clinically significant distress or impairment in one or more areas (social, occupational or other important areas). Either anhedonia (a loss of pleasure or interest) and / or a depressed mood must be present. All symptoms should be present most of the time, i.e. most of the day, nearly every day

• Depressed mood
• Anhedonia (significant diminished pleasure and/or interest in all or nearly all activities)
• Significant weight loss or gain (more than a 5% of body weight fluctuation per month) or change in appetite
• Insomnia or hypersomnia
• Psychomotor agitation or retardation (observable by others)
• Fatigue or loss of energy
• Feelings of worthlessness or excessive or inappropriate guilt
• Diminished capacity to think or concentrate, or indecisiveness
• Suicidal ideation or actions or recurrent thoughts of death (not just fear of death or dying)

Exclusions:

• Symptoms do not meet the criteria for a mixed episode
• Symptoms are not due to the direct physiological effects of a substance (e.g. substance abuse or medication side-effect) or a general medical condition (e.g. hypothyroidism)
• Symptoms are not better accounted for by bereavement

Differential Diagnosis

A differential diagnosis is established based on all possible conditions that could account for symptoms. Different conditions are eliminated from the list through further medical investigations in order to reach a diagnosis. Conditions usually included in the differential diagnosis are:

• Physiological conditions, like hypothyroidism
• Bipolar Disorder
• Schizophrenia (although depression could co-exist)
• Dementia
• Postnatal depression
• Seasonal Affective Disorder
• Bereavement
• Substance abuse
• Drug side effects - medication that may cause depression include lithium, central nervous system depressants like the benzodiazipines (e.g. valium, atarax, xanax) and lipid soluble beta-blockers

Medical Treatment

The medical treatment of depression depends on whether the condition is mild, moderate or severe. For mild depression, the first course of action is usually watchful waiting by arranging further assessment with a follow-up appointment , usually within two weeks. The general treatment strategy tend to be centred around psychotherapy, medication, lifestyle management and self help. Psychotherapeutic approaches include cognitive behavioural therapy, counseling and problem-solving therapy. Medications are generally not a first line method for mild depression, but could be prescribed immediately on diagnosis for moderate to severe depression. Standard medication are anti-depressants. Lifestyle management and self help strategies focus on sleep and anxiety management, getting plenty of exercise, guided self help through provision of written materials or computerised CBT. Mild to moderate depression is usually managed by a primary care physician / GP, whilst moderate to severe depression is generally treated by a psychiatrist.

Prognosis

The prognosis largely depend on the severity of symptoms. Under medical supervision, the prognosis could be better. About 4 out of 5 depression sufferers under psychiatric care will experience at least one more depressive episode at a later stage in their life. The average number of recurrent episodes experienced is four. One in three depression sufferers under the care of their GP will remain well during the following 10 years, whilst two out of three will either not improve or relapse. One out of five sufferers does not respond to treatment and the disease follows a chronic course. For those suffering from a chronic mild type of depression, called dysthymia, the outlook is generally 50/50. Half of dysthemic patients improve after a year whilst the other half remain chronically ill.

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