5. Depression

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6 months ago

चिंतारोग (काळजीरोग )/ नैराश्य उदासीनता/भयगंड

या आजारामध्ये रुग्णास उदास, एकाकी व निराश वाटते, रडू येते, झोप भूक कमी लागते, वजन कमी किंवा जास्त होते, स्वभाव चिडचिडा होतो, आत्महत्येचे विचार येतात, आत्मविश्वासाची कमतरता जाणवते.

नैराश्य ही मनाची एकाकीपणा आणि निराशा जाणवणारी अवस्था आहे. सर्वाधिक आढळणारा मानसिक आजार आहे. या आजारामुळे नेहमी उदास वाटते, दैनंदिन कामे करण्याची इच्छा होत नाही आणि आनंददायक गोष्टींत कमी रस वाटतो.

BACKGROUND

Hippocrates used the term ‘Melancholia’ (Greek for ‘Black Bile’)
The term Depression is derived from the Latin word deprimere (meaning ‘to press down’)
Emil Kraepelin: ‘Depressive states’ as part of ‘Manic-Depressive Psychosis’
Henry Maudsley: ‘Affective disorders’
Kurt Schneider: ‘Endogenous’ (melancholic) and ‘Reactive’ (neurotic) types
DSM-I: Depressive Reaction
DSM-II: Depressive Neurosis
DSM-III onwards: Major Depressive Disorder
ICD-10: Depressive Episode / Recurrent Depressive Disorder

CLINICAL FEATURES

Depressed mood that is clearly abnormal for the person
Anhedonia (inability to derive pleasure from normally pleasurable activities)
Decreased energy / increased fatiguability
Sleep disturbance (usually early morning awakening)
Appetite disturbance (usually decreased + wt. loss)
Diurnal mood variation (usually worse in mornings)
Reduced concentration
Psychomotor agitation/retardation
Feeling hopeless/helpless/worthless
Suicidal ideas / plans / acts

DEPRESSION VS. BIPOLAR DISORDER

Mood disorders are also called ‘Affective’ disorders

The 2 main Mood disorders

Depression
Bipolar disorder

In Depression, the patient experiences one or more episodes of low mood Also called ‘Unipolar disorder’

In Bipolar disorder, the patient experiences:

Episodes of both low mood (Depression) and abnormally elevated mood (Hypomania or Mania), (or)
2 or more episodes of abnormally elevated mood (Hypomania or Mania)

PSYCHOTIC SYMPTOMS

Both delusions and hallucinations can occur
Mood-congruent psychotic symptoms:

Delusions of:

Guilt
Worthlessness
Hypochondriasis
Nihilism (body rotting, world ending soon, etc.)
Voices accusing or condemning the patient
Mood-incongruent psychotic symptoms:
Delusions of reference or persecution
Voices speaking about affectively neutral topics

DEPRESSION IN BIPOLAR DISORDER

Depression occurring in bipolar disorder is generally clinically indistinguishable from unipolar depression
So, in any first episode of depression, the possibility of bipolar disorder needs to be borne in mind
A patient with significant Depression may not be able to recall any happy memories (including hypomanic / manic episodes). So, always useful to get information from a family member/friend who has known the patient for many years
40% of patients with Bipolar disorder are initially diagnosed as Unipolar Depression

Some features that may suggest bipolar

Atypical features (increased sleep, increased appetite)
Psychomotor retardation
More frequent episodes
Family history of bipolar disorder
Lower age of onset
Male gender (equal gender prevalence for bipolar)
More abrupt onset

DEPRESSION IN ICD-10

F32 Depressive episode
F32.0 Mild
F32.1 Moderate
F32.2 Severe without psychotic symptoms
F32.3 Severe with psychotic symptoms
30 mood-congruent psychotic symptoms
31 mood-incongruent psychotic symptoms
F33 Recurrent depressive

This diagnosis is used for those with 2 or more episodes of depression
The previous diagnosis (Depressive episode) is used for the first episode of depression
In Recurrent depressive disorder, rate the current episode as mild, moderate or severe as above, or whether the patient is currently in remission

ENDOGENOUS VS. REACTIVE DEPRESSION

These subtypes are no longer included in ICD or DSM

Endogenous

Depression occurring spontaneously without any external stressor
Also called ‘Melancholic’ Depression / ‘Psychotic’ Depression
Characterized by prominent biological /somatic symptoms of depression
More severe symptoms (e.g. Psychomotor retardation) / psychotic symptoms
May respond better to TCAs than SSRIS
More likely to need Antipsychotics / ECT

Reactive Depression:

Depression occurring in response to a clearly identified external stressor (e.g. Bereavement]
Also called ‘Neurotic’ depression
Less severe
More affective symptoms (e.g. Imitability, anxiety, guilt, etc.)
Significant overlap with ‘Adjustment disorder’
Spontaneous recovery more common

ATYPICAL DEPRESSION

In ‘Typical’ Depression: there is reduced sleep, reduced appetite and weight loss

In ‘Atypical Depression: there is hypersomnia (increased sleep), increased appetite and weight gain

Other

Feeling of heaviness in arms and legs (‘Leaden paralysis’)
Excessive sensitivity to interpersonal problems (‘Interpersonal rejection sensitivity’)
Bipolar Depression tends to have more Atypical features than Unipolar Depression
Seasonal Affective Disorder is characterized by Atypical features
Atypical Depression may respond better to MAOIs than TCAs or SSRIs

EPIDEMIOLOGY – UNIPOLAR DEPRESSION

Lifetime prevalence is about 15%
Annual incidence is about 5%
About twice as common in women than men
Average age of onset: about 30 years
Peak age groups of onset:

30 to 44 years
18 to 29 years

AETIOLOGY OF DEPRESSION – GENETICS

First degree relatives have a 3-fold increased risk of depression
Genetics less important for late-onset depression
Two susceptibility loci MDDI and MDD2 (on chromosomes 12 and 15 respectively) have been identified
Other potential genes: TPH2, HTR3A, HTR3B genes
Polymorphism of the serotonin transporter (SLC6A4) gene (on chromosome 17)-5HTTLP: short allele homozygosity or heterozygosity associated with increased risk of depression, in response to stressful life events, than long allele homozygosity
Genetic factors may also mediate drug response or side-effects