Depressed people think they know themselves, but maybe they only know depression.~Mark Epstein

Depression or low mood is a common illness affecting millions worldwide. Contrary to popular belief it is not a sign of weakness and does not necessarily require any life stress to cause it.

What Is It?

Depression is a state of low mood caused by low levels of two chemicals in the brain, namely, Serotonin and Nor-Adrenaline.

What are the Symptoms

Depression is usually experienced as

1. A state of low mood, Feeling miserable and tearful without much reason.
2. She feels tired without having done much.
3. Seems to have lost pleasure in things she used to enjoy previously.
4. Person looses confidence in herself
5. She tends to blame herself for everything.
6. She is unable to concentrate for example while watching TV or reading.
7. Has problems with sleep like waking up earlier than her usual time in the morning
8. Doesn’t feel hungry and can lose weight
9. thinks that the future is bleak
10. May lose interest in sex
11. Have thoughts of harming herself or committing suicide.

All these symptoms are present in varying combinations of varying severity.

How Common Is It

Females are twice as likely to get it. While it can ouccer at all ages, the commonest age is around 28 years. During any 1 year, 2-5% of the population is depressed! According to WHO, depression is one of the biggest disease burden on mankind.

What Causes It

There is no clear answer but research has shown that it is heritable and hence more common amongst the relatives of the depressed. It can occur secondary to physical illnesses especially thyroid gland under-activity. It can be caused by certain drugs like steroids, L-dopa etc. Life events such as sudden death of a loved one, moving home and social stress such as money worries and problems with relations can also cause it.

Treatment

This can broadly be classified into three types:

1) Medicines (Antidepressants): These are the mainstay of treatment. These are of various types but tend to affect the levels of one or both of the chemicals, serotonin and nor-adrenaline. Usually 60% of patients respond to the first antidepressant that they are prescribed while the remaining will require a change or combination of medications.

2) Psychotherapy: This either alone or in combination with antidepressants can be a effective remedy for medication. For more on this, kindly refer to the link on psychotherapies on this website

3) ECT: This is an effective treatment for depression with response rates approaching 80%. It is only used in treatment resistant or life threatening cases. For more look at the ECT link on this website.

What to expect from treatment

Usually the outcome for people with depression is good. However majority of patients suffer multiple episodes in their lifetime and a few of these fail to respond to any treatment. There is a definate risk of dying by suicide in people with depression.

What if you don't respond to anti depressant (Treatment Pathway)

Kindly note this is a rough guide based upon recommendations in the UK and local practices may vary. I have used generic (salt) names insted of trade names as the latter can vary.

When a patient fails to respond to the first antidepressant prescribed

• If response to a standard dose of an antidepressant is inadequate, and there are no significant sideeffects, consider a gradual increase in dose to maximum.
• Consider switching to another antidepressant if there has been no response after a month. If there has been a partial response, a decision to switch can be postponed until 6 weeks.
• If an antidepressant has not been effective or is poorly tolerated and, after considering a range of other treatment options, the decision is made to offer a further course of antidepressants, then
switch to another single antidepressant.
• Choices for a second antidepressant include a different SSRI or mirtazapine; alternatives include
moclobemide, reboxetine and tricyclic antidepressants

Chronic Depression

Combination of individual CBT and antidepressant medication.

Treatment-resistant depression

• For all people whose depression is treatment resistant, consider the combination of antidepressant medication with individual CBT of 16 to 20 sessions over 6 to 9 months.
• For patients with treatment-resistant moderate depression who have relapsed while taking, or
after finishing, a course of antidepressants, consider the combination of antidepressant medication with CBT.
• Consider a trial of lithium augmentation for patients whose depression has failed to respond to
several antidepressants and who are prepared to tolerate the burdens associated with its use.
• Venlafaxine may be considered for patients who have failed two adequate trials of alternative
antidepressants.

Recurrent depression and relapse prevention

• Continue antidepressants for 2 years for people who have had two or more depressive episodes in the recent past and who have experienced significant functional impairment during the episodes.
• Maintain the antidepressant dose used for relapse prevention at the level at which acute treatment was effective.
• Patients who have had multiple episodes of depression, and who have had a good response to
treatment with an antidepressant and lithium augmentation, should remain on the combination for at least 6 months.
• When patients are taking an antidepressant with lithium augmentation, if one drug is to be
discontinued, this should be lithium in preference to the antidepressant.

Psychotic depression

• For patients with psychotic depression, consider augmentation of the current treatment plan with antipsychotic medication.

Atypical depression

• Consider phenelzine whose depression has atypical features, and who have not responded to, or who cannot tolerate, an SSRI.

SUICIDE

Some people with depression and other mental illnesses become suicidal. Anyone who is thinking about committing suicide needs immediate attention, preferably from a mental health professional or a physician. Anyone who talks about suicide should be taken seriously this is especially important in the case of children and the elderly. Risk for suicide appears to be higher earlier in the course of the illness. Therefore, recognizing the disorder early and learning how best to manage it may decrease the risk of death by suicide.
Signs and symptoms that may accompany suicidal feelings include:

• talking about feeling suicidal or wanting to die
• feeling hopeless, that nothing will ever change or get better
• feeling helpless, that nothing one does makes any difference
• feeling like a burden to family and friends
• abusing alcohol or drugs
• putting affairs in order (e.g., organizing finances or giving away possessions to prepare for one's death)
• writing a suicide note
• putting oneself in harm's way, or in situations where there is a danger of being killed

If you are feeling suicidal or know someone who is:

• call a doctor right away to get immediate help
• make sure you, or the suicidal person, are not left alone
• make sure that access is prevented to large amounts of medication, weapons, or other items that could be used for self-harm

It is important to understand that suicidal feelings and actions are symptoms of an illness that can be treated. With proper treatment, suicidal feelings can be overcome.