Q&As on Depression

During a depressive episode, the individual experiences consistently depressed mood, which is not in line with their circumstances. This low mood persists for most of the day, nearly every day, and is not significantly influenced by external events. This state of low mood must persist for at least 2 weeks and cannot be attributed to the effects of a substance or another medical condition.

In order to diagnose an episode of depression, at least five of the followin symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either depressed mood or loss of interest or pleasure. Markedly diminished interest or pleasure in all, or almost all activities. Experiencing significant weight loss without dieting, or weight gain, along with changes in appetite, insomnia or excessive sleep. Others may notice observable restlessness or slowing down of movements. Feeling tired, worthless, or excessively guilty, and having difficulty concentrating or making decisions. Also, having recurrent thoughts of death, suicidal ideation, or attempts at suicide. The symptoms cause significant distress or impact in social, work, or other important areas of life.

When differentiating between grief and a major depressive episode (MDE), it's important to consider the following distinctions: In grief, the primary emotional experience is feelings of emptiness and loss, while in MDE, there is a persistent depressed mood and the inability to look forward to happiness or pleasure. The distress in grief usually lessens over time, typically over days to weeks and occurs in waves, often triggered by thoughts or reminders of the deceased. On the other hand, the depressed mood in MDE is more enduring and not linked to specific thoughts or concerns. Grief may be punctuated by positive emotions and humor, which are atypical of the constant unhappiness and misery associated with MDE. In grief, there may be a preoccupation with thoughts and memories of the deceased, rather than the self-critical or pessimistic ruminations found in MDE. Self-esteem is generally maintained in grief, whereas in MDE, feelings of worthlessness and self-loathing are common. If bereaved individuals think about death and dying, their thoughts are usually focused on the deceased, possibly about "joining" the deceased. On the other hand, in MDE, such thoughts are focused on ending one's own life due to feeling worthless, undeserving of life, or unable to cope with the pain of depression.

Psychotherapy involves treating psychiatric and behavioral disorders through communication based on a psychological model of illness. It starts with a patient seeking relief from current symptoms or prevention of their recurrence. Different types of psychotherapy, such as cognitive behavioral therapy or interpersonal therapy, can be effective for treating depression. Mental health professional may also suggest other types of therapies.

Pharmacotherapy focuses on the brain circuitry that regulates mood. The three key chemicals involved are norepinephrine, serotonin, and dopamine. Research indicates that in depression, the brain circuits that utilize these chemicals are not functioning properly. Antidepressants adjust these chemicals to improve the functioning of the circuits, which can help enhance mood.

In Electroconvulsive Therapy (ECT), electrical currents are passed through the brain to impact the function and effect of neurotransmitters, relieving depression. ECT is typically used for individuals who do not respond to medications, are unable to use antidepressants due to health issues, or are at significant risk of suicide.

TMS, or transcranial magnetic stimulation, could be considered for individuals who have not had success with antidepressants. Throughout TMS, a treatment coil is positioned on your scalp to deliver brief magnetic pulses, thereby activating nerve cells in the brain responsible for mood regulation and depression. This action creates a magnetic field that generates an electric current, stimulating nerve cells in the prefrontal cortex of the brain, an area crucial for mood control.

Treatment recommendations for depression vary depending on its severity. Guidelines suggest that mild depression may improve with exercise or waiting it out, but psychotherapy or antidepressants could be considered if initial efforts are ineffective. For moderate major depression, first-line treatments include antidepressant monotherapy, psychotherapy, or a combination of both. Combined treatment is more effective than medication alone. Severe depression may require antidepressants combined with antipsychotic medication, electroconvulsive therapy, or a combination of antidepressants and psychotherapy. Cognitive-behavioral Therapy (CBT) and Interpersonal Therapy (IPT) are the most supported methods, both in acute and maintenance phases of MDD, and have been studied in combination with antidepressants. Antidepressants should ideally be accompanied by psychological interventions, and treatment methods should be personalized based on individual needs and preferences.

It's crucial to remember that people with depression are at a higher risk of experiencing more illnesses throughout their lives compared to the general population. Unfortunately, they are also more likely to go untreated, which increases the risk of death from undiagnosed and untreated illnesses such as cancer, diabetes, heart disease, or HIV by 40-60%. Depression and anxiety significantly increase the likelihood of heart attack and stroke, and the reluctance to undergo tests and treatment further complicates the situation. Patients with mood disorders tend to lead less active lifestyles, pay less attention to the nutritional value of their food, and often consume unhealthy high-calorie, high-carbohydrate, and high-fat foods. These factors can lead to obesity, hypertension, diabetes, and atherosclerosis, which are often referred to as silent killers due to their long-term impact on life quality and expectancy. Additionally, people with depression may have reduced willpower in fighting illnesses, including cancer, which affects their chances of recovery, as anticancer therapy is often undertaken only in the advanced stages of the disease for these individuals.

The psychological effects of untreated depression are far-reaching and include:

- Increased risk of recurring depressive episodes

- Development of anxiety disorders, primarily generalized anxiety disorder

- Personality changes such as deepening hypochondriac, hysterical, and anankastic features

- Persistent sexual disorders

- Psychosomatic complaints, such as headaches, stomach aches, or chest pains that persist for a long time, occurring without specific causes, but causing increasing anxiety and intensifying the depressive state

- Reduced effectiveness of tasks performed, leading to deterioration in academic performance and work efficiency

- Progressive social alienation

-The most direct of the tragic effects of untreated depression are suicide attempts.

Depression and anxiety disorders are prevalent in both the community and in primary care settings. Individuals with depression often exhibit symptoms of anxiety disorders, and conversely, those with anxiety disorders frequently also experience depression. It can be challenging to differentiate between the two, but it is crucial to recognize and address both conditions, as they are linked to significant levels of illness and death. About 85% of individuals with depression also encounter significant symptoms of anxiety, while comorbid depression is present in up to 90% of individuals with anxiety disorders. As many as 25% of patients in general practice have both anxiety and depression. The co-occurrence of anxiety and depression is primarily attributed to a shared genetic predisposition to both conditions or one disorder being a secondary outcome of the other. Both depression and specific anxiety disorders necessitate suitable treatment. Psychological interventions such as cognitive behavioral therapy, antidepressants, and occasionally antipsychotics have demonstrated effectiveness in addressing both depression and anxiety. The combination of anxiety and depression intensifies the severity, raises the risk of suicide, increases disability, and makes treatment less effective. Moreover, the combined conditions lead to more profound psychological, physical, social, and workplace impairment compared to either disorder alone.

Recent evidence indicates that bipolar disorder may be more prevalent than previously believed, with experts in the field suggesting rates of 5% to 7%. There is compelling evidence that bipolar disorder is often either overlooked or misdiagnosed as major depressive disorder. The most common misdiagnosis is major depressive disorder, occurring in 60% of cases. Patients with bipolar disorder often initially present with depressive episodes. Up to 35% to 60% of patients experience a major depressive episode before experiencing a manic episode. Additionally, patients tend to downplay their experience of hypomanic episodes, contributing to misdiagnosis as depression. Antidepressants have been associated with adverse outcomes in patients with bipolar disorder; misdiagnosis of depression and treatment with antidepressants put approximately 30% to 40% of bipolar patients at risk of inducing manic episodes. Patients with bipolar disorder who take antidepressants also have an increased risk of rapid cycling. Current guidelines recommend prescribing antidepressants alongside a mood stabilizer for patients with bipolar disorder. Misdiagnosis and inappropriate treatment of patients with bipolar disorder also delay the use of mood stabilizers and may increase the risk of treatment resistance as more episodes are experienced. There is also evidence that appropriate treatment of bipolar disorders can reduce suicide risk and that earlier recognition and treatment of bipolar disorders in children and adolescents can reduce subsequent risk of substance abuse.

The connection between depression and dementia is intricate and not yet fully understood. There are various perspectives on how these two conditions are related and the underlying neurobiological mechanisms involved. In general, there is compelling evidence supporting the idea that depression in early life can increase the risk of developing dementia later in life and that depression in later life can be an early sign of dementia. Additionally, there is evidence indicating that both conditions exhibit similar neurobiological changes, particularly in white matter disease, suggesting shared risk factors or a common pattern of neuronal damage. These findings emphasize the need to investigate whether effectively treating depressive episodes can reduce the prevalence of dementia. It is also important for clinicians to be attentive to late-life depression as a potential early stage of dementia development and to carefully monitor these individuals for future cognitive impairment.

Such changes can encompass physical activity, dietary choices, spending time outdoors, nurturing relationships, engaging in leisure activities, practicing relaxation techniques, managing stress, incorporating spirituality, and helping others.

Exercise. Engaging in regular physical activity can be just as effective in addressing depression as taking medication. Exercise not only increases the levels of serotonin, endorphins, and other mood-enhancing brain chemicals, but also stimulates the generation of new brain cells and connections, similar to the way antidepressants work. Even a 30-minute walk each day can have a significant impact. To achieve optimal outcomes, strive for 30 to 60 minutes of aerobic exercise on a regular basis.

Nutrition. Maintaining a nutritious diet is crucial for your physical and mental well-being. Consuming small, balanced meals at regular intervals can help sustain your energy levels and reduce fluctuations in mood. Even though you might be tempted to reach for sugary snacks for a rapid energy increase, opting for complex carbohydrates is a more beneficial decision. They will provide sustainable energy without the subsequent sugar crash.

Sleep. The amount of sleep you get can significantly impact your mood. Inadequate sleep can worsen symptoms of depression. Lack of sleep can intensify feelings of irritability, mood swings, gloominess, and exhaustion. It's important to ensure you achieve a sufficient amount of sleep every night. Few individuals function optimally with less than seven hours of sleep each night. Strive to get between seven to nine hours of sleep per night.

Social support. Remember to stay connected with friends and family regularly since having strong social connections can decrease feelings of isolation, which is a significant risk factor for depression. You might also want to think about participating in a class or group as another way to maintain social connections.

Stress reduction. Adjust your life to cope with and lessen stress. Excessive stress worsens depression and increases the likelihood of future depression. Identify the elements of your life that cause stress, like an overwhelming workload or unsupportive relationships, and discover ways to reduce their influence.

Unipolar depression is twice as common among women in their fertile years compared to men. Current biological theories suggest that stages of life with declining levels of estrogen could trigger depression. Psychological theories point to low self-esteem, sensitivity to lack of social support, comorbidity with anxiety, and inward aggression in women, and outward aggression and comorbidity with alcohol abuse in men. Social theories highlight the preponderance of women in poverty and economic dependence.

The most consistent finding in the study of major depressive disorder is that it is more prevalent in females. However, there are no clear differences between genders in terms of symptoms, course, treatment response, or functional consequences. Suicide is a greater risk for men and increases with age, while suicide attempts are more common in women and decrease with age.

When choosing treatment, it's crucial to consider whether a woman is planning a pregnancy, as it significantly influences the choice of treatment method. In such cases, psychotherapy is recommended as the first line of treatment. If pharmacotherapy is necessary or preferred by the patient, the doctor selects a drug that is safe during pregnancy.

Sexual dysfunction is a common and potentially distressing side effect of antidepressants that affects both men and women, leading to non-adherence to medication. The management of antidepressant-induced sexual dysfunction requires an individualized approach, such as considering other causes, dose reduction, adding medication to treat the adverse effect, or switching to a different antidepressant.