One fine morning while going for a morning walk, I saw a group of senior citizens sitting in a park and chatting. Some were cracking jokes while some were trying to impress others with their spiritual talks. Some others were discussing their problems with each other. Out of curiosity, I got some snacks for all and joined them. We all started enjoying the discussion with snacks. Relishing the snacks, Sharma uncle sighed and said “It’s so tasty. We don’t get all these to eat at home. Only bland diet.” Hearing to this, Mishra uncle said “that’s because, we might have digestion or other health problems. So we are not allowed to have such food at home regularly.” Casually Sharma uncle asked Mishra uncle “so how’s life after retirement?” Mishra uncle let out a sigh and replied “How would it be you think? After retirement, there’s nothing to do, getting bored of sitting at home. No work, nowhere to go. On top of it, only with pension, it’s becoming difficult to manage the household expenses. My wife gets irritated. Children are not yet established. My daughter is yet to marry. I am not able to sleep because of all this stress. At times I feel very sad. Anyways leave it. Tell me how’s your life?” Now it was Sharma uncle’s turn. He thought for some time, let out a deep breath and said “At least, you have a full family to stay with. We are two persons, staying alone in a big house. One of my Sons is in Delhi, other in USA. My daughter is at Bangalore. All are busy in their lives and with their families. Who cares for old parents? If one does not have time and the other does not have money to give to old parents. As you know it’s difficult to manage family expenses with pension only. On top of it, every month Rs. 4000-5000 gets spent on treatment of these old age problems like diabetes, hypertension and arthritis. It’s really difficult to manage all these with pension. My wife always has pain in her knees. At times, we try to share our problems with children. Instead of listening to us, they start enumerating their problems. Because of all this, my wife is very upset. She often sits and cries. She doesn’t eat much and doesn’t feel like doing anything. She keeps complaining of headache, backache etc. Few years back, suddenly one day she came to know that her only brother expired in an accident. She was not able to accept this. Since then, she remains depressed thinking about her brother. This was all before my retirement. Somehow it was manageable till now. But now when our children have left and we are staying alone its becoming more difficult. Moreover the careless attitude of our children towards us has further worsened her condition. She feels helpless, worthless, as if she does not have a desire to live. She is going to suffer till she dies.”
I was quietly listening to them. I explained to them that because of certain stressful circumstances, people often experience such symptoms. Now a day, many medicines are available to treat such problems. Aunty would be fine if she would take medicine regularly. Sharma uncle was surprised. He said “really is it possible? I shall get her to meet you tomorrow. Please treat her. Both of us are facing a lot of problems because of this.” I said “definitely I shall prescribe medicines but you have to ensure that she takes the medicines regularly.” Uncle further asked “will she be fine after taking medicines?” I said “definitely, but these treatment are a bit prolonged treatment. You need to have patience. It would take at least two to six weeks before you would be able to notice some marked difference in her. In between you need to be regularly in touch with me as and when advised. Doses need to be revised based on the progress of the disease.”
Uncle asked “will there be any harm or reactions due to these medications? I said “At times, few people get some side effects like stomach upset, palpitation, tremor in hand, dry mouth, blurring of vision etc. If you get any such symptom, consult me. You can also seek the help of a psychologist. They talk to the patient and try to find out the cause of depression. They counsel the patient accordingly. This is called Psychotherapy. Psychotherapy sessions usually last for half an hour to one hour initially. Later weekly sessions are required. Family members have an equally important role to play. They should be caring and compassionate towards the patient to prevent relapse. This is called “Family therapy.” At times such patient also benefit from group discussions with each other. This is called “group therapy”. Society also plays an important role in the treatment of such patients. It’s our duty to help these patients recover and lead a productive life. If we all try sincerely, then these patients will definitely be cured.”
After listening to all this, uncle felt quite relieved and hopeful. It was time for me to leave and get back to my daily routine. I took leave from them with a satisfaction that now Sharma uncle was convinced and knew what to do.
1.How common is major depression?
The lifetime risk of depression in male is 8-12% and female is 20–26%.
2.How serious an illness is major depression?
Major depression is as serious as diabetes or heart disease. The depressive disorders are associated with poor physical and social functioning. Depression increases mortality significantly through suicide, accidents, and exacerbation of medical illness.
3.What percentage of the medically ill have a depressive disorder?
Rates rise with severity of medical illness, so that hospitalized patients
have higher rates (20–33%) of depression than primary care clinic patients (5–20%). The depressed person often initially presents a somatic complaint (pain, insomnia, or fatigue), and the diagnosis of depression often is missed by either patient or clinician.
4.How do you diagnose depression?
Depression is diagnosed by the history, physical examination, mental status exam, or response to a screening measure. Collaborative sources, such as relatives and past records, will help when the patient’s responses are ambiguous, insufficient, or distorted by depression. One should suspect depression in a person when he or she is sad most of the time, decreased interest in pleasurable work or feels fatigue in doing little work. Sleep and appetite is disturbed and is not able to concentrate. Sadness of mood is usually associated with pessimism, which can result in depressive ideas. These are hopelessness (there is no hope for the future), helplessness (no help is possible now and worthlessness (feeling of inadequacy and inferiority).
5.What are the causes of depression?
- Genetic factors are very important in making an individual vulnerable to mood disorder.
- Abnormality of monoamines (Serotonin, norepinephrine and dopamine in the central nervous system at one or more sites. Acetylcholine and Gaba are also involved.
- Mood disorders are prominently present in many endocrine disorders, such as hypothyroidism, cushing’s disease and Addision’s disease.
- Stressful life events
- Learned helplessness, negative thinking
- What is the effect of depression on medical illness?
Depressive disorders complicate the course of medical illness through a variety of possible mechanisms: magnifying pain, impairing adherence to regimens, decreasing social supports, and dysregulating humoral and immunologic systems. Untreated depression has been shown to increase rates of death dramatically. Depressed patients with chronic medical conditions show significantly more disability than non-depressed patients.
7.What percentage of depressed patients commit suicide? What percentage try?
About 15% of hospitalized depressed patients eventually commit suicide. About 10 times as many make suicidal acts. Depressive disorders are associated with about 80% of suicidal events. Other factors that increase the risk of suicide for the depressed person include alcohol and drug abuse, panic disorder and other states of
intense anxiety, family history of suicide, medical illness, hopelessness, few social supports, recent personal loss, and unemployment. Treatment of the factors which contribute to suicide risk dramatically reduces both the immediate and chronic risks.
8.After the first episode, how likely is a patient to have a second major depressive episode?
More than 50% of those who have a first major depressive episode will have a recurrence. Untreated episodes generally last 6–24 months, with two thirds achieving a spontaneous full recovery. Risk factors for recurrences include incomplete recovery, previous recurrences, a strong family history of recurrent affective disorders, and
a history of “double depression,” i.e., a major depression superimposed on dysthymia.
9.What are other psychiatric conditions that mimic depression?
- Mood disorder resulting from a medical condition
- Substance-induced mood disorder
- Bipolar disorder
- Attention deficit/hyperactivity disorder
- Adjustment disorder with depressed mood
- Sad mood
- What are the options for treating a major depressive episode?
Every patient who receives the diagnosis of major depression should learn the options for treatment. They consist of antidepressant medications, psychotherapy, electroconvulsive therapy, RTMS therapy or some combination of these. A substantial body of research has established the efficacy of each of these methods of treatment.
Furthermore, with systematic trials of treatment by qualified psychiatrist, 80–90% of people with major depression recover.
psychotherapy (1 hour a week for 20 weeks) is a substantial trial if the therapy is focused on managing the depression. Significant symptom relief often occurs within 4–6 weeks. An adequate trial of an antidepressant is 4–6 weeks on a therapeutic level. The antidepressants for which the level/response relationship has been well studied include impiramine, desipramine, amitriptyline, Mirtazapine, Desvenlafaxine, nortriptyline, selective serotonin reuptake inhibitors (fluoxetine, citalopram, paroxetine, sertraline).
11. When should a depressed person must be treated by a psychiatrist?
- Suicidal risk
- Need for hospitalization
- Failure of an adequate antidepressant trial
- Complicated medical or psychiatric comorbidity
- Evaluation for pharmacotherapy