Year : 2017 | Volume
: 3 | Issue : 1 | Page : 1--2
Depression: Let's talk
Department of Psychiatry, Pondicherry Institute of Medical Sciences, Kalapet, Puducherry, India
Department of Psychiatry, Pondicherry Institute of Medical Sciences, Kalapet, Puducherry
|How to cite this article:|
Solomon S. Depression: Let's talk.J Curr Res Sci Med 2017;3:1-2
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Solomon S. Depression: Let's talk. J Curr Res Sci Med [serial online] 2017 [cited 2017 Dec 17 ];3:1-2
Available from: http://www.jcrsmed.org/text.asp?2017/3/1/1/210334
The World Health Organization has aptly chosen “Depression: Let's talk” as the theme for World Health Day April 2017 since depression is ranked as the second leading cause of years lived with disability in the global burden of disease 2010 study. The lifetime prevalence of depression ranges from 5% to 17% and is much higher when subsyndromal depressive symptoms are also taken into consideration. Women are twice as likely to be affected as men, and the postpartum period presents significantly increased risk.
Depression has a biopsychosocial causation, with contribution from genetic factors, neurotransmitter, neuroendocrine and neuroimmune systems, environmental stress, and maladaptive patterns of thinking and behaving. The hallmark features of depression are a persistent low mood, loss of interest or enjoyment in previously pleasurable activities (anhedonia), and reduced energy. Other signs and symptoms include reduced concentration and attention, reduced self-esteem and self-confidence, ideas of guilt and unworthiness, difficulty in thinking and concentrating, bleak views about the future, ideas, acts of self-harm or suicide, and disturbances in sleep and appetite. According to the diagnostic systems, these symptoms should be present for 2 weeks to qualify for a depressive episode. Psychotic symptoms such as delusions (of guilt, poverty, hypochondriasis) and hallucinations (defamatory voices) may be present in severe depression. Depressive symptoms of lower severity may have their onset following an acute stressful event such as loss of a job, in which case a diagnosis of an adjustment disorder is made. Manifestations in children may include depressed or irritable mood, excessive clinging to parents, school refusal, absenteeism, and somatic complaints. Withdrawal from social activities, substance abuse, antisocial behavior, restlessness, and poor academic performance are common in depressed adolescents.
Early diagnosis and treatment of depression can result in significant reduction in morbidity and mortality. Depressed individuals have significant impairment in socio-occupational functioning leading to reduced work performance and high economic costs. Depression is a major risk factor for suicide. Patients with persistent insomnia, motor retardation, hopelessness, and delusions are particularly at high risk. Women with postpartum psychosis which is characterized predominantly by depression have 5% risk of suicide and 4% risk of infanticide. Depression is also a risk factor for the development of substance use disorders, which further increases the risk of suicide.
Depression is commonly comorbid with medical disorders such as diabetes, coronary artery disease, malignancy, thyroid dysfunction, rheumatoid arthritis, Parkinson's disease, epilepsy, stroke, dementia, and HIV infection, and it results in magnification of disability, increased resource consumption, drug noncompliance, and eventually poorer outcome of these disorders. Depression can also adversely affect health habits which play a role in the etiology and prognosis of noncommunicable diseases.
Despite its high prevalence and associated morbidity and mortality through suicide, depression is underrecognized and undertreated. Patients do not seek help because of the stigma attached to mental illness. Depressive symptoms such as worthlessness, hopelessness, helplessness, guilt feelings, and social withdrawal may act as barriers to seek help from physicians and patients' social network. Around 50% of depressed individuals consulting primary care physicians go undiagnosed due to a number of reasons. Physicians may lack knowledge regarding the varied presentations of depression. Patients may not present with the classic symptoms mentioned earlier but with unexplained medical symptoms which 'mask' the underlying depression and hence the physician may focus only on the medical aspects. Even when physicians perceive distress in patients, they may explain it away as a normal response to their psychosocial stressors and/or normal aging. The presence of certain features, such as severe anhedonia, early morning awakening, weight loss, and profound feelings of guilt, points toward a greater degree of severity of depression and helps differentiate the condition from an adjustment disorder. On the contrary, another common misconception among nonpsychiatrist physicians and the general public is that depression cannot happen in the absence of any stressful event, discounting the medical model of depression. Even when depression is diagnosed, it is not adequately treated because of lack of expertise in the use of antidepressant medications, psychological therapies, and lack of time. The dearth of psychiatrists and resource allocation to the mental health needs of developing countries adds to the bleakness of the scenario.
It is important that every physician enquires about depressive symptoms in patients who present with unexplained somatic symptoms, especially pain syndromes, subjective distress out of proportion to the underlying medical condition, nonadherence to treatment and acts of self-harm, those with chronic medical conditions, substance use disorders, and ongoing psychosocial stressors. Questions regarding their mood, interests, sleep, and appetite can shed light on the probability of an underlying depression. Patients with depression should be asked direct questions about ideas, plans, or acts of self-harm, since, contrary to popular belief, asking about suicide does not increase the risk of suicide. Instead, it offers the patient an opportunity to discuss their symptoms and receive appropriate care. Physicians who ask open-ended questions, listen well, and have sensitivity to the emotional cues of the patient are more likely to detect depression. Patients with mild episodes and/or psychosocial stressors will benefit from psychological therapies such as cognitive behavior therapies (modifying maladaptive patterns of thinking, behavioral activation) and problem-solving delivered by trained health workers and social support. Referral to a specialist is essential for those diagnosed with moderate, severe episodes and comorbid psychiatric disorders. Prophylactic treatment with antidepressants may also be required for preventing recurrences in those with recurrent depressive disorder.
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