There has been a significant rise in the number of people with depression all over the world. WHO estimates that more than 300 million people globally are living with depression. Depression can have a significant impact on the quality of life of the individual and can adversely affect the psycho-social functioning of a person. It can lead to problems in social, educational and occupational functioning resulting in significant dysfunction. Depression can affect men, women, children, adults and the elderly population. It can happen to anybody at any time!
A person experiencing depression depicts clinical symptoms such as feelings of sadness, hopelessness, helplessness and worthlessness. When a person feels depressed, he or she may have a negative view about self, world and the future. They may experience negative thoughts, self defeating thoughts and feelings of low mood and lack of enjoyment in previously pleasurable activities. A person suffering from depression can show features of low self esteem, crying spells, negative thoughts, low mood, irritability, etc. Depression can also affect cognitive and biological functions. A person experiencing a depressive episode can have decreased or increased need for sleep, appetite and sexuality. The individuals may gain and/or lose weight noticeably. They may also experience cognitive distortions such as maximization, minimization, selective abstraction, arbitrary inference and over generalization.
Depression can also bring about cognitive schemas of loneliness, helplessness and feeling of abandonment. It can also lead to difficulties in focussing on studies and job and can also affect relationship with loved ones and friends. A person may become extremely negative and reactive and can feel so low and depleted of mental energy that even ordinary day to day tasks can appear to be very difficult and heavy. Depression can also make the person experience thoughts, ideas, images related to self harm and death wishes and this can be very distressing, delusional and traumatising. Depression can become severe and can complicate into severe depression with psychotic features and may even lead to suicidal tendencies! Nothing can be more sad, traumatic and unfortunate to lose a loved one forever. Life once lost is lost forever! Nothing can then later bring it back! Hence, it is very important to understand that the serious complications arising out of depression. Mental health must be every one’s priority. One must not wait till the situation goes out of hand! The earlier it is detected, better is the outcome. If one finds themselves or their near and dear ones suffering from any of the symptoms of depression, they must seek help of a psychiatrist on a priority basis!
WHY DOES DEPRESSION OCCUR?
Depression can occur due a number of factors. No single cause can be attributed to it! Depression is considered a mood disorder which occurs due to neurochemical changes in the brain. Neurotransmitters such as serotonin, norepinephrine, dopamine, etc are hypothesized to be involved. At the neuronal level in the brain, changes start happening when one experiences depression. These neuronal changes also affect sleep, appetite, cognition, thinking, etc. Amygdala, Hippocampus, Prefrontal Cortex, and other vital brain areas are hypothesized to play a role in depression. Genetic and heritability factors also play a role in depression. Immunological and neuroendocrine pathways are considered too. Epigenetic factors and neurotropic factors are also attributed in research. Psychosocial theories such as stressful life events, day to day stressors and social factors can also make a person depressed via epigenetic and neuronal factors. Stressors can be loss of loved one, financial loss, failure in exams, job loss, break up, marital separation, parent’s divorce, etc which literature highlights that different people cope and respond differently to stress! Some people try to cope and adjust with stress and some people just break down completely! This can be due to multifactorial pathways related to stress response, individual coping, genetic vulnerability, neuronal expression, neurobiological as well as epigenetic changes in the brain.
TYPES OF DEPRESSION:
Depression can be classified as mild, moderate and severe depression. Moderate depression can occur with somatic syndrome and without somatic syndrome. Severe depression can occur with psychotic features or without psychotic features.
Sometimes classical depression is described to have weight loss, loss of appetite and loss of sexual interest. Atypical depression is described to have irritability, craving for sweets, excessive sleep, excessive appetite and excessive sexual interest. Depression can be unipolar depression if the person experiences only repeated depressive episodes. If depression occurs in a person who has experienced mania or hypomania, then it is considered Bipolar Depression. Depression can be a single episode or can come in recurrent episodes and is termed Recurrent Depressive Disorder. Depression that does not fulfil all the criteria of depression but the person has some few symptoms, then it is considered subsyndromic depression. Depression can also occur in the aftermath of a major psychosis illness and it is termed post-psychotic depression. These various types are described in literature on various presentations that patients with depression can experience or manifest. These also help in further appropriate planning for diagnostic work up and clinical management.
The last decade has witnessed significant advances in neurosciences of depression. These have been in multiple domains of epigenetics, neuro-modulation, neurostimulation, animal models and cognitive neurosciences which has helped in improving the understanding about depression. Technology has also begun showing interest in depression especially the role of artificial intelligence and machine learning has helped in improving knowledge regarding depression, its diagnosis and clinical management via evidence based technological oriented solutions to scientifically study depression, its impact and treatment and prevention approaches.
DEPRESSION AND COMORBIDITY:
Depression can occur along with medical conditions such as Diabetes, Hypertension, Coronary Artery Disease, Thyroid Dysfunction, etc. Depression can also occur along with anxiety disorders, sleep disorder, eating disorders, sexual dysfunction etc.
There are certain diagnostic criteria for depression which psychiatrists are trained to do, which are: clinically interview patients and plan treatment accordingly. DSM-5 and ICD 11 have well defined chapters on diagnostic criteria for depression as a psychiatric disorder. History taking and detailed mental status examination can help the psychiatrist diagnose depression based on these classificatory criteria. Depression has varied presentations and multiple subtypes. Certain screens and scales can also be helpful to assess and quantify the type and severity of depression and dysfunction associated with depression.
The treatment of depression largely comprises of psychopharmacological and psychotherapy treatments. Psychiatrists after clinically interviewing the person may plan and advise certain medical investigations, imaging and psychological assessments and rating scales based on guidelines, expertise, clinical presentation, complexity and severity of symptoms. Antidepressants are prescribed as evidence based pharmacological treatment for depression. Individual counselling sessions to offer psychological support and help provide empathic care to help recover from depression are also important. Individual and caregiver sessions regarding psycho-education about depression as an illness, treatment options, role of medications, role of therapy, combination approaches, evidence base, duration of treatment, expected outcomes and sessions to address questions and concerns by patients and caregivers can be helpful in improving patient and caregiver understanding, improving compliance and making a holistic treatment plan. Certain evidence based psychotherapy such as CBT, IPT and psychosocial rehabilitation can be done in collaboration with allied mental health professionals in a holistic manner! The aim of treatment consists of immediate, short term and long term goals spread over time to provide relief over depression and its symptoms. Psychological support helps the person to recover across multiple domains to the best optimal level of functioning such as psychosocial, educational, interpersonal and occupational domains!
Although depression is very common, there are significant factors which limit access to care and delay treatment! Stigma towards mental health remains an important factor to prevent patients and families to seek professional treatment! Progress has been made over the last few decades in stigma reduction via collective efforts of psychiatrists, allied mental professionals, patient and caregiver groups through various international, national and local organizations, institutions and bodies and diverse stakeholders to create awareness regarding mental health problems and depression in the community. There have been community awareness programs, social awareness drives, public psychoeducation, Celebration of World Mental Health Week, Suicide prevention, etc. Media and technology have also started focussing on creating awareness regarding depression. However, considering the vast and diverse population with skewed rural and urban distribution, efforts and resources are unevenly distributed with huge pockets of lack of availability of trained psychiatrists and allied mental health professionals, manpower and resources in the rural areas.
Misinformation, Prejudice, Lack of Awareness, Attitudinal problems, can play a role in delaying access to care for patients with depression for even urban patients where resources maybe available but barriers of stigma may delay access and seeking treatment. Early identification and treatment can be helpful in improving prognosis and treatment response. It is advisable to seek help and treatment from mental health professionals when one is depressed so that one can get clinically improved and recover from depression.
HIGHLIGHTS /OVERVIEW ABOUT DEPRESSION:
• Depression is a real illness.
• Stressful Life events, genetic vulnerability, neurobiological changes, etc can link to depression.
• Depression can occur in children, adolescents, adults and elderly i.e. all age groups.
• Untreated depression can worsen outcomes in underlying medical conditions such as hypertension, diabetes, coronary heart disease, etc.
• Depression can get complicated if untreated and unattended and can lead to suicide.
• Early identification and treatment can be very helpful in improving prognosis.
• Evidence based medications and evidence based psychotherapy are effective for depression.
MYTHS AND FACTS ABOUT DEPRESSION:
Myth: Depression affects certain people only! Depression occurs as one becomes old! Young people cannot be depressed! Depression affects only certain socioeconomic class of people!
Fact: Depression affects all socioeconomic classes of people and can be found in males and females across all groups. Depression can be seen in children and adolescent, adults and elderly globally.
Myth: Depression is a problem of will power of a person! A person who is having depression is a weak person! Strong people cannot become depressed!?”
Fact: Depression is a real illness. It has nothing to do with will power of person! Anyone can suffer from depression anytime! Depression has nothing to do with weakness or strength!
Myth: There is no such thing like depression! Anyone can feel sad! There is no need to visit or seek help! Only mad people visit psychiatrists.
Fact: Negative events can make us feel sad momentarily, however depression as a psychiatric disorder is a medical condition characterized by greater than 2 weeks of low mood, sadness, crying spells, negative thoughts, anhedonia, sleep and appetite dysfunction, etc. Not seeking treatment for depression and leaving it untreated can lead to further complications making depression more severe.
Myth: Depression is just a phase! It is completely manageable on its own by increasing self motivation and increasing self positivity by reading self help books and watching positive inspirational booster videos and there is no need to consult psychiatrist or mental health professionals! It will recover on its own!”
Fact: Living in denial of depression, not taking care of one’s own mental health and not seeking help because of stigma and lack of awareness and trying to self manage a serious illness on their own without making any attempt to seek proper professional help and misinformed ways can lead to worsening of depression! Untreated Depressive episode can even complicate to severe depression with psychosis and can also lead to suicide if left untreated. It is advisable to seek professional help from psychiatrists and mental health professionals if one is depressed and is not to be neglected.