January 4, 2012, 7:39 pm

by Dr. R. A. R. Perera M.B.B.S. (Cey) M.Sc. Psych (Col) F.R.C.G.P.A. (Aus) Consultant Psychologist O.A.C.C.P.P.(C) Canada CPsych (Canada) C.Ht (USA)

Depression is such common experience that everyone encounters it at some time in his or her lives. Its relationship to anxiety is close and anxiety tends to proceed to depression to follow an unpleasant experience. Sometimes the depression is clearly outside the limits of normality and we regard it as an illness.

There are two main depressive illnesses.

Neurotic or reactive depression in which the gloominess or sadness described by the person follows some significant event but the misery and grief are out of proportion to it in intensity and duration.

This second is endogenous depression, which is more severe. it occurs more in females (3.2) and is genetically determined. the term ‘masked depression’ is sometimes used when somatic features predominate; the patient sometimes denies depression although careful questioning reveals the true state. Such cases are frequently misdiagnosed and subjected to intense and unnecessary investigations and surgery.

Neurotic depression usually comes on abruptly in relation to an unpleasant occurrence. it could be explained as a loss event experienced by the patient and his sensitivity to minor stress and other evidence of a predisposed neurotic personality. the first episode usually occurs in early adult life. the patient feels miserable and unhappy and expresses self-pity, often displaying as much anxiety as depression. the symptoms fluctuate in response to daily events. often tending to become worse towards evening, the patient becomes tearful, feeling helpless and hopeless, clearly expecting sympathy for a condition, which is beyond his control and for which he is not responsible. Concentration is impaired and the patient easily becomes fatigued. A wide variety of symptoms like headache, stomach problems, reduced appetite and weight loss could be present. Sleep disturbance is usual, typically waking up early in the morning (e.g.2-3 a.m.) and inability to fall asleep after that. Suicidal ideas and attempts are common. many cases of neurotic depression last only days or weeks. the nature of provocative event is important. If for example this is some insoluble interpersonal conflict the illness may persist indefinitely. the final outcome depends on whether the precipitating problem can be resolved and on the nature of the patient’s personality.

Endogenous depression differs from neurotic depression qualitatively. In practice the distinction is often difficult to make because the person may react, as to other life disturbing event. If the depression is mild, the person may not appreciate that he is ill and may not seek medical help, but observant friends and family members will notice the difference. Patients with moderately severe depression are more likely to seek medical help. the illness usually develops gradually over a few days or weeks. His interests become restricted or lost, concentration is impaired and his thoughts are often dominated by feelings of guilt and unworthiness. In some patients he is concerned that he may have some serious physical ailment, particularly cancer or heart disease. the face will show a sad expression but may still smile deceptively so that the correct diagnosis is not made. Fatigue and loss of energy are marked and in many cases sleep is disturbed with restless and early wakening. Weight loss up to 5 kg, suicidal thoughts varying in intensity from the feeling that if by chance one died it would not matter, to the conviction that death is the only way to obtain relief. Sexual desire is reduced, constipation is frequent and menstruation becomes irregular. In severe cases the patient becomes immobile, mute, and will refuse to eat. This endogenous depression may last for 6-8 months to many years.

Many drugs, which are taken for high blood pressure and contraceptive pills, can cause depression. some levers infective hepatitis and some cancers (cancer of the pancreas) can cause depression. some times dementia (forgetfulness) can show as a depression.

The majority of depressed patients can be treated as an outpatient Admission as advisable if the depression is severe if suicide is likely or if an organic illness is suspected. A patient living alone requires admission for a milder illness than one who has a supportive and sensible family. If he is able to continue working he should be encouraged to do so. Although it is important to reassure him that he will get better, it is vital that this should be done sensibly. He should certainly not be told that all he needs is a quite holiday. This may well have an adverse effect, causing him to loose faith in his caregiver and to conclude that suicide is the only answer.

Psychotherapy and antidepressant medications are the most useful methods to treat depression. In many cases social problems and environmental difficulties should be corrected and a social health worker is most helpful in these circumstances. ECT or Electro Convulsive Therapy is used if the depression is severe and if it endangers the life of the patient. This is an effective and fast acting treatment. following ECT, patients may experience headache and muscle pain, but they are mild and short lived.