Depression

INTRODUCTION

Depressive illness, which is probably the greatest masquerade of general practice, is one of the commonest illnesses in medicine and is often confused with other illnesses. Other coexisting mental disorders, e.g. anxiety or substance abuse, should be ruled out.

Many episodes of depression are transient and should be regarded as normal but 10% of the population have significant depressive illness.

MAJOR DEPRESSION

Diagnostic guidelines for major depression (MDD) At least five of the following 9 symptoms with at least one of anhedonia or depressed mood for >2 weeks:

1. Depressed mood

2. Anhedonia (decreased interest or pleasure)

3. Sleep change: increased/decreased

4. Guilt/worthlessness

5. Decreased energy

6. Impaired or increased concentration

7. Change of appetite or weight

8. Psychomotor agitation or retardation

9. Suicide ideation

MINOR DEPRESSION

Minor depression is basically a condition where fluctuations of symptoms occur with some vague somatic symptoms and a transient lowering of mood that can respond to environmental influences. The diagnosis is based on a total of 2–4 symptoms from the above list, incl. 1 and 2. These patients usually respond in time to simple psychotherapy, reassurance and support.

DEPRESSION IN THE ELDERLY

Depression can have bizarre features in the elderly and may be misdiagnosed as dementia or psychosis. Agitated depression is the most frequent type of depression in the aged. Features may include histrionic behaviour, delusions and disordered thinking.

DEPRESSION IN CHILDREN

Sadness is common in children but depression also occurs and is characterised by feelings of helplessness, worthlessness and despair. Parents and doctors both tend to be unaware of depression in children.

Major depression in children and adolescents may be diagnosed using the same criteria as for adults, namely loss of interest in usual activities and the presence of a sad or irritable mood, persisting for 2 wks or more.

PERINATAL DEPRESSION

Depression occurring in the antenatal period or in the 12 mths after delivery ( 381).

Management of depression (adults)

Important considerations from the outset are:

• Is the patient a suicide risk?

• Have secondary causes been excluded, e.g. hypothyroidism, drug misuse/adverse effects?

• Does the patient require inpatient assessment?

• Is referral to a specialist psychiatrist indicated?

If the symptoms are major and the patient appears in poor health or is a suicide risk, referral is appropriate.

The basic treatments are:

• Psychotherapy, incl. education, reassurance and support. All patients require minor psychotherapy. More sophisticated techniques, such as cognitive behavioural therapy, can be used for selected patients. Cognitive therapy involves teaching patients new ways of positive thinking, which have to be relevant and achievable for the patient.

• Pharmacological agents (monotherapy is preferable)

• Electroconvulsive treatment

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