Depression Disease

BASICS

DESCRIPTION

Depression is a primary mood disorder that is characterized by a depressed mood and/or a decrease in interest in things that used to give pleasure (anhedonia). It may have several accompanying symptoms and signs. It may accompany several different somatic and psychological illnesses. The etiology is multifactorial, but it is thought that depression is associated changes in receptor-neurotransmitter relationship in the limbic system. Serotonin and norepinephrine are the primary neurotransmitters involved, but dopamine also has been related to depression. A family history of depression is a common finding.

Bipolar disorder has a prominent depressive phase, but is a different clinical entity that is treated differently from depression
System(s) affected: Nervous
Genetics: Possible defect on chromosome II or X
Incidence/Prevalence in USA: Estimated that 5-20% of population will experience a significant depression at some time
Predominant age:
- Bipolar - mean, 30 years
- Unipolar - mean, 40 years
Predominant sex: Female > Male

SIGNS AND SYMPTOMS

Depressed mood
Anhedonia
Depression is probable when at least four of the following exist in addition to depressed mood or anhedonia:
- Poor appetite - either weight gain or loss (may eat or drink out of boredom or reasons other than appetite)
- Sleep disorder - either insomnia or hypersomnia
- Fatigue - tiredness is out of proportion to the amount of energy expended
- Psychomotor retardation or agitation (restlessness, irritability or withdrawal)
- Poor self image - self reproach, excessive guilt
- Difficulty in concentrating, poor memory, unable to make decisions
- Suicidal ideation. Sometimes when people begin to recover they gain enough energy to think about and sometimes to attempt suicide.

CAUSES

Impaired synthesis of the neurotransmitters
Increased breakdown or metabolism of the neurotransmitters
Increased pump uptake of the neurotransmitters. The action potential is passed on from neuron to neuron. Following this the neurotransmitter is (1) reabsorbed into the neuron where it is either destroyed by an enzyme or actively removed by a reuptake pump and stored until needed or (2) destroyed by monoamine oxidase (MAO) located in the mitochondria.
Lack of these neurotransmitters causes certain types of depression, e.g., decreased norepinephrine causes dullness and lethargy, while decreased serotonin causes irritability, hostility and suicide ideation
Environmental factors and learned behavior may effect neurotransmitters and/or have independent influence on depression
Many life stresses and losses

RISK FACTORS

Females more likely to develop depressive illness than males
Strong family history (depression, suicide, alcoholism, other substance abuse)
Presence of chronic disease, especially multiple diseases
Migraine headaches
Back pain
Chronic pain
Recent myocardial infarction
Peptic ulcer disease
Insomnia
Stressful situations
Adolescence
Advancing age
Retirement
Children with behavioral disorders, especially hyperactivity
Substance abuse
Menopause
Losses

DIAGNOSIS

LABORATORY

Depression is a clinical diagnosis. Laboratory tests are used primarily to rule out other diagnoses.

Drugs that may alter lab results: All psychoactive drugs
Disorders that may alter lab results: Thyroid disease

PATHOLOGICAL FINDINGS

N/A

SPECIAL TESTS

ECG (diagnosis of arrhythmia, especially heart block)
EEG (only if organic brain disease is suspected)

IMAGING

CT or MRI of brain, if organic brain syndrome (OBS) included in differential

DIAGNOSTIC PROCEDURES

Depression is primarily a clinical diagnosis that depends on skillfully eliciting family, social and psychosocial factors
Validated standard rating scales can assist in identifying and following depressed patients
- Zung Self-rating Depression Scale
- BDI - Beck's Depression Inventory
- CES-D Scale - Criteria for Epidemiologic Studies - Depression Scale
- CDI - Children's Depression Inventory
- Yesavage's Geriatric Depression Scale

TREATMENT

APPROPRIATE HEALTH CARE

Outpatient; inpatient care is indicated for seriously depressed or suicidal patients

GENERAL MEASURES

Psychotherapeutic interventions act synergistically with pharmacologic therapy
Psychotherapy alone is effective and appropriate for milder forms of depression
Use the correct medication
Use the correct dosage
Use the correct medication long enough
ECT can be very effective in refractory cases

SURGICAL MEASURES

N/A

ACTIVITY

No restrictions

DIET

No special diet

PATIENT EDUCATION

Carefully teach about medications
Consider referral to support groups
Stress need for long-term treatment and followup
Recommend reading for patients, e.g., How to Cope With Depression by DePaulo and Ablow; Depression is a Treatable Illness: A Patient's Guide, AHCPR Publications Clearinghouse
Contact local support groups through National Depression Manic Depression Association (DMDA) (800)82-MDMDA

FOLLOW UP

PREVENTION/AVOIDANCE

See Causes and Risk factors

POSSIBLE COMPLICATIONS

Suicide
Failure to improve

EXPECTED COURSE AND PROGNOSIS

This is one of the most rewarding conditions to treat because once you find the right drug, the right dose, and have a positive relationship with the patient, improvement is likely

MISCELLANEOUS

ASSOCIATED CONDITIONS

Manic depression (bipolar)
Schizophrenia
Schizo-affective disorders
Psycho-physiological disorders
Physical disorders
Cyclothymic and grief reactions
Alcoholism

AGE-RELATED FACTORS

Pediatric: Depression occurs in children
Geriatric: More common in elderly and difficult to precisely diagnose. Depression frequently coexists with dementia or delirium.
Others: N/A

PREGNANCY

Caution in using psychoactive medications in pregnancy. Rely on psychotherapy and support groups until pregnancy is completed.

OTHER NOTES

Depression is the fourth most common reason to visit the family physician
Like so many other medical illnesses with psychological symptoms, family, doctors and patients tend to try to overlook this condition because they feel they should be able to control it themselves
Attention deficit syndromes are being treated with antidepressants. They may be more effective than methylphenidate (Ritalin) or amphetamines.
Bipolar disorder may first present as an episode of depression

ABBREVIATIONS

OBS = organic brain syndrome
TCA = tricyclic antidepressant
TSH = thyroid stimulating hormone

Clinical Investigations

ROLE OF HOMOEOPATHY

Holistic healing that treats the person, not just the disease. Experience gentle, lasting wellness with expert constitutional care.