DepressionEverybody’s mood varies according to events in the world around them. People are happy when they achieve something or saddened when they fail a test or lose something. When they are sad, some people say they are ‘depressed’, but the clinical depressions that are seen by doctors differ from the low mood broughton by everyday setbacks. Psychiatrists see a range of more severe mood disturbances and so find it easier to distinguish these from the normal variations of mood seen in the community. General practitioners (GP’s) need to be sensitive enough to distinguish emotional reactions to setbacks in life from anxiety syndromes, and clinical depressions. The general idea is that anxiety disorders, depressive episodes, and adjustment reactions are all different entities, but in practice it is not always that clear-cut.
Major depression, as defined by psychiatrists, is unfortunately relatively common. What is depression? The term ‘affect’ refers to one’s mood or ‘spirits.’ ‘Affective disorder’ refers to changes in mood that occur during an episode of illness marked by extreme sadness (depression) or excitement (mania) or both. Depression is a disorder of affect. Affective disorders are predominantly disturbances of mood that are severe in nature and persistent despite the influence of external events. Depression is characterized by severe and persistent low mood, which is often unresponsive to the efforts of friends and family to cheer the sufferer up. Patients who suffer with repeated episodes of depression have a Recurrent Depressive Disorder.
Depressive episodes can be classified into mild, moderate, and severe types, with or without psychotic symptoms. To be classified as depression, an episode must last more than two weeks. A condition where the mood is persistently low, but does not quite fulfill all the criteria for a depressive episode, is sometimes called ‘dysthymia.’ Community studies have found that depression is prevalent between 5 and 20% of all people. About 10% of people over age 65 will have a major depressive episode. The incidence of depression is higher in women and in urban settings rather than rural settings. Clinical features of depression Mild depressive episodes typically include features such as: .
Sadness and crying, . Loss of interest in and loss of enjoyment of life (), . Poor attention and concentration, . Low self-esteem and ideas of unworthiness, .
A bleak view of the future and the world in general, . Poor sleep and appetite. People with mild depressive episodes find it difficult to continue with their work and social lives, but usually continue to function, although less than normal. Moderate depressive episodes have a wider range of symptoms, which a represent usually to a greater degree. Sufferers find it very difficult to function normally at work or home.
Severe depressive episodes typically may also include features such as: . Great distress and agitation, . Slowed thought and movement (psychomotor retardation), . Ideas of guilt, . Suicidal fantasies or plans which may be acted upon, . Pronounced somatic symptoms, .
Psychotic symptoms. People with severe depressive episodes find it impossible to continue with their work, domestic and social lives, and usually cease to function in these areas. Depression is often accompanied by slowing of thought processes and biological features of everyday life which differ from a normal sense of sadness. Crying is a frequent symptom, although some individuals are reluctant to admit this, and others feel so depressed it that is as if they have ‘gone beyond crying’. Suicidal ideas occur in most depressed people, and asking about these is a crucial aspect of their assessment.
Depressed patients often find it a relief to talk about these ideas with their doctor. Asking about suicidal ideas is a sequential process, beginning with questions about the severity of the low mood. The doctor can then ask if the patient has ever felt that life is not worth living. A ‘yes’ could be followed by inquiring whether the patient has ever felt like ending their own life. Finally the doctor needs to assess if the patient has any particular plans in mind. Case History: Janet Janet Gordon was aged 35 when she lost her job as a manager of a department store.
At first she looked on her period of unemployment as an opportunity to try out activities she had previously no time for. She went hill-walking and painting every day. Two months later she had lost interest in these things and was despairing that she would never work again, although she had an exemplary work record. Her sleep at night was poor and she had started going to bed during the day. Janet cried almost daily and had lost interest in the food she cooked. All food tasted bland, she said to her mother (who was concerned when she saw how much weight Janet had lost).
At her mother’s suggestion Janet went to her family doctor where she complained about how tired she always felt. She asked for some sleeping tablets to help her sleep at night. Case History: Alan Alan Benson was brought to the accident and emergency department by his son. Alan had tried to hang himself from the banisters at the family home. Fortunately the clothes’ line that he had chosen to hang himself with had broken under his weight. When he was seen by the psychiatrist Alan had a red weal mark around his throat from the noose.
He was staring at a fixed point on the floor. Now and then he would groan deeply and whisper to himself. He kept repeating the words ‘I’m for it… I’m for it now.’ He would not make eye contact with the doctor and initially refused to answer questions.
His son said that the previous week his father had stopped going to work as a bailiff after he found out that his wife was having an affair. He had watched her obsessively for two days, not letting her out of his sight. Then a few day sago he had taken to his bed, and lain there for hours and hours not moving, not speaking, not eating and not drinking. He had talked about how everything was his fault and had at times been pleading with an unseen person to forgive him. He felt that he had committed some unpardonable crime and that he should now be punished.
Armed with this information the psychiatrist talked to Mr. Benson again. This time Mr. Benson replied, even if only briefly. He said that God was telling him that his wife had to find another man because her husband had been so evil. He confessed that he had once had an affair himself many years before, and that God had told him in the last week that He had punished Mr.
Benson with syphilis. His wife could be spared from the syphilis only if he killed himself. Once he was dead, he thought, his wife could begin a clean life with another man. Differential Diagnosis Many physical disorders can be present with depressive illness.
They include: hypothyroidism, hyperthyroidism, Addison’s disease, Cushing’s disease, electrolyte disturbances, alcoholism, drug abuse, carcinoma and dietary deficiencies (B 12, B 1, and folic acid). Various drugs can cause depression. Psychological disorders that may mimic depression include adjustment reactions, anorexia, bulimia, anxiety disorders, substance abuse, obsessive-compulsive disorder, dysthymia, seasonal affective disorder, and abnormal bereavement reactions. Panic disorder commonly co-exists with or pre-dates depression, (Andrade et al, 1994). Diagnosing and treating underlying physical causes must be attempted and are key factors in the correct prognosis of the actual cause of a persons depression. Risk factors for depression: .
In Young Adults: . Urban dwellers, . Unemployment, . Physical ill-health, . Previous affective illness, . Family history of depression, .
Childhood abuse / trauma , . Loss of mother before age 11, . Looking after several young children, . No confidence, . Bereavement. In Older People: .
Bereavement of a close figure in last six months, . Loneliness (but not living alone), . Lack of Satisfaction with Life, . Female Sex.
The risk factors for older people identified above have some predictive value in identifying people at risk of depression three years later. Life satisfaction and bereavement help predict recurrences of depressive illness. The higher prevalence of depression amongst women could be because women are more prone to depressive illness biologically or because of their social roles, or could be because male depression is under-recognized, or incorrectly labeled. However, suicide is more common among men than women. It is worth remembering that only 50% of depressed patients who present to their GP are correctly diagnosed as suffering with depression.
Most depressed people in the community do not receive treatment. Over 90% of depressed elderly people in the community suffer without treatment. Armed with knowledge of its prevalence, causes and common features, one might assume that it is a simple task to diagnose depression in general practice settings. Unfortunately it isn’t. Certainly having a high index of suspicion and a professional willingness to consider the possibility of depression are important factors in our ability to diagnose depression.
Additionally patients also have a significant part to play in enabling – or preventing us – from arriving at a diagnosis of depression. It is rare to find depression as a simple, unitary diagnosis in general practice. It is much more common for patients to show a combination of problems – some physical, others social – within which depression can all to easily be either unnoticed, or assumed to be inevitable and therefore untreatable. Feeling eta l  and Tyler et al  have shown that severe depression is much more likely to be missed if associated with significant physical illness. Moreover, many patients have strong reservations about disclosing depression to their GPs.
Depression itself often contains feelings of hopelessness and despair. Patients may therefore feel that there is no point in talking to the doctor about it since there is nothing that they or anybody else can do about it. These negative perspectives can be compounded by GPs – often unwittingly – if they give the impression of rushing through their consultations and being unable or unwilling to sit and listen to our patients’ concerns. There is still a considerable stigma attached to mental illness. Many people have a great fear of the consequences of acknowledging their depression to a professional person: they may be ‘carted off to a loony bin’, or written off as ” mad’. If the word ‘depression’ appears in medical notes they fear – often correctly – that this will be prejudicial to future employment or insurance prospects.
Fear of antidepressant medication is also a very important obstacle to disclosure of depression. A study undertaken by the Defeat Depression campaign showed that many people confuse antidepressants with, and are genuinely worried about becoming dependent – ‘getting hooked’ on them, and about unpleasant effects of withdrawal. There is considerable public skepticism about the effectiveness of antidepressants. Most patients would prefer to be offered counseling rather than drugs, but doubt if they will be given such a choice by their GP. Faced with this complex barrage of obstacles, it is perhaps surprising that we ever do manage to make a diagnosis of depression! However, there are many things that can be done to increase the chances of detection. We need to help some patients to re attribute physical symptoms to psychological causes.
Ifa patient is feeling tired all the time, has no energy or interest in life and is sleeping very badly, these chances of their being depressed are very high. Often a direct question – ‘do you think you may be depressed?’ – is all that is needed to move the consultation onto a psychological agenda. Sometimes it is better to take a more indirect route. The word ‘stress’ is a very useful bridge, since it intrinsically has both physical and mental components: ‘Are under any extra or unusual stress at the moment?’ , or ‘Do you think these symptoms might be due to stress?’ are effective open ended questions. For those few patients who appear reluctant to consider any diagnosis of depression it may initially be most profitable to concentrate on its more physical manifestations – sleep and appetite disturbance, or energy loss – without forcing the issue of their underlying causation. We must also accept patients’ genuine anxieties about the shame attached to depression, and acknowledge their concerns about the harmful effects of drug therapies.
Good basic consultation skills include inquiry into patients ” expectations and fears about the nature and consequences of their problems. This will take us a long way towards understanding not only whether our patients are depressed, but the context and meaning that their depression has for them. Many people experience enormous relief when their problems are explored in this way. To a large extent, therefore, effective diagnosis is also the most crucial aspect of effective treatment.
Management There are two important dimensions to be considered in deciding how best to manage depression in general practice. First, mild depression may often be managed effectively through sympathetic exploration of the factors precipitating it – whether physical illness, a recent personal crisis in work or relationships- and encouragement of the patient’s own coping mechanisms and supportive informal social networks. Moderate and severe depression have been shown to respond to antidepressant drug therapy. As we have seen it is essential to discuss patients’ anxieties and expectations of drug treatment before starting it.
Also, drugs should be viewed as complementary rather than alternative to talking about depression. Problem-solving is a useful and simple skill to develop. The first stage is the creation of a problem list. This is something usually best done by the patient between sessions, although they may need some help initially.
The patient writes down a list of problems which he is experiencing at present, either in terms of how he feels – miserable, tired, bored etc. – or in terms of things he is unable to do – go to work, enjoy hobbies, etc. He can then rank these problems in order of importance, and set goals for overcoming them. These goals should be staged and not too ambitious.
For instance, if feeling bored is a central concern, it might be useful to discuss which aspects of life give the most pleasure and interest – watching TV soaps, walking the dog, having a bath, and agreeing that the patient will spend a set amount of time each day doing just that. Problem-solving works well in conjunction with drug therapy, and directly addresses the sense of hopelessness that is central to depression. It enables both doctor and patient to achieve a sense of purpose and direction, and provides a practical means of monitoring and demonstrating progress. The second dimension to the management of depression in general practice concerns the views and experience of the doctor and the patient. GPs vary considerably in their skills, experience and confidence in dealing with depression.
Some of us will prefer to refer early to other professional colleagues, whether counselors, psychologists or psychiatrists, while others are more comfortable about managing even acute and severe problems. Patients, as we have seen, may also have strong views about the causes, effects and treatment of depression. If we are to manage it effectively we must take these into account. When people feel they are being listened to, and have genuine choices about what happens to them – whether they receive counseling or drug therapy or both, whether they are referred for psychiatric opinion or not – they are more likely to be committed to the management plan that emerges.
Many patients, even when expressing suicidal thoughts, may prefer to be managed at home by their GP than be admitted to a psychiatric ward: the problem then becomes one for us, in assessing the degree of risk and responsibility that we feel able to sustain. It is worth remembering that, involving our patients in genuine decision-making about the management of their illness is intrinsically therapeutic. Studies of treatments versus placebo have endorsed the value of physical therapies such as ECT (electric-convulsive treatment or ‘shock therapy’) in severe depression and antidepressants in mild, moderate and severe depression. Most depressive illnesses respond to such treatments. Tricyclic antidepressants need to betaken regularly in adequate doses for an adequate length of time. Inadequate doses of Tricyclic antidepressant are linked to suicidal behavior in some studies.
Newer antidepressants (SSRIs and RIM As) offer a relative safety in overdose. Some psychological treatments have proven efficacy, notably cognitive-behavioral therapy and interpersonal psychotherapy for mild and moderate depression. Their drawbacks are that they take longer to have an effect and are not well-standardized. There is evidence that cognitive behavioral therapy and interpersonal psychotherapy may help maintain health when combined with antidepressant medication, but there is as yet little evidence to suggest that counseling alone is a suitable treatment for major depression.
Where there is evidence of continued relationship or family difficulties psychotherapy may be particularly useful. Cases of moderate to severe depression may need vigorous treatment by a community psychiatric team and close follow-up to help prevent relapse and improve prognosis. Severely depressed patients with or without psychotic symptoms require inpatient admission and may respond best to electro-convulsive treatment. Who to refer people to: Counselors, psychotherapists, community psychiatric nurses, occupational therapists, social workers and psychologists, unless also medically qualified, are not trained to diagnose depression, recognize its origin, or formulate long-term management plans.
If referring on to one of these agencies as the sole provider of psychological care, the onus is on the general practitioner to diagnose the depression correctly, to be certain about its origin and to have a clear long-term management protocol in mind. The General practitioner must therefore be sure to have excluded physical illness as a cause of the depression before referring on to the non-medically trained. Prognosis The long-term prognosis for depression is still guarded, however. Up to 15% of patients who have had depression will go on to kill themselves. Recurrent episodes of depression are the norm rather than the exception. Long-term studies of lithium suggest that it may help to reduce the number of episodes and prevent suicide.
Studies of long-term use of antidepressants suggest beneficial effects. Long-term efficacy of psychotherapy and counseling has not been proven. Learning points: depression. Depressive illness affects 10-18% of the adult population… Depressive illness in the community is largely untreated, because patients generally do not seek medical help, and of those that do seek help only about 60% of those that see their family doctor are recognized by them as suffering from depression…
Depressive illness is treatable – over 80% of cases can be resolved… Treatment may include antidepressants, (SSRIs, tricyclics, MIRA drugs, or MAO Is), ECT (for severe or delusional depression) or psychotherapy for mild (particularly cognitive therapy).