by Sandhya Singh, Nurse Practitioner, Psychiatry
According to the World Health Organization, major depression is the leading cause of disability worldwide among people aged 5 years or older. It is the most common and widespread psychiatric disorder, and it takes a significant toll on individuals, families, and society. Depression also negatively affects the economy through diminished productivity and use of healthcare resources. Suicide is the leading cause of death among depressed persons.
Symptoms of Depression
- Sad mood – “the saddest you have ever felt”
- Hopelessness and helplessness, and in advanced stages, suicidal thoughts
- Irritability or anxiety
- Increased or decreased sleep and appetite
- Anhedonia – inability to take pleasure from activities that once gave pleasure
- Decreased energy and motivation
- Cognitive deficits
- Distractibility
- Diminished ability to think or concentrate
- Slowed speech and thinking
- Forgetfulness, particularly short term memory
- Inability to make a decision, including difficulty with initiation of a thought, planning, execution of the idea, and anticipation of the results
How does depression start?
Depression usually starts with a life stressor that becomes overwhelming to a person, such as the sudden death of a child or spouse. Usually when a person starts to feel depressed, they try to help themselves by self medicating with alcohol or drugs. If a person does not feel better after the normal process of working through a problem, they start to feel clinically depressed, as evidenced by any combination of the symptoms listed above. Usually, this person will go to his/her medical doctor, who then will start a medication, most likely an antidepressant. If the treatment is not successful, the person is then referred to a psychiatrist or a psychiatric nurse practitioner. At this time, many people feel more hopeless, because they have supposedly already failed one attempt at treatment.
Why is this a problem?
Generally, internal medical doctors are not able to monitor and dose antidepressants to the “therapeutic” dose. The problem is that statistics have repeatedly shown that at least 50% of people with an episode of depression will have another episode because they were inadequately treated in the first place. This means that patients were treated until there was relief of some of the symptoms, but not all symptoms, for a time period less than 6 months.
Once there is a 2nd or 3rd episode of depression, people become 80% - 90% more likely to have another episode. What starts to happen is that life stressors are no longer the triggers for depression; people just get depressed. Unfortunately, the more episodes a person has, the harder the depression becomes to treat.
Course of Treatment
People should seek help prior to the depression becoming overwhelming
A single medication, in combination with psychotherapy should be started
The dose of the medication should be increased as per treatment guidelines, while the person is being monitored for therapeutic and adverse effects.
If a person is able to tolerate the medication to the therapeutic dose with relief of symptoms, the dose should be maintained for at least 6 months.
The prescribing provider can start to reduce the dose of medication with complete symptom resolution for at least 6 months.
Psychotherapy may or may not be continued once the medication has been completely stopped.
** This process generally takes about 1 year of medication and therapy compliance.
If a person cannot tolerate one medication because of side effects, or there is not complete resolution of symptoms, a different medication from the same drug family should be tried.
If complete remission of symptoms is not attained after the maximally tolerated dose is tried, a second medication should be added, or a different medication from a different drug family should be tried.
** People with this type of complicated illness course tend to require longer-term treatment, meaning greater than one year.
Summary
Nearly 15 million American adults suffer from depression each year. Recognizing the symptoms in ones’ self or in loved ones is the first step in combating this disorder. However, it is imperative that depression is treated aggressively, hopefully during a first episode to prevent recurrence and worsening prognosis and morbidity.
References
1. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC, American Psychiatric Association, 2000.
2.Goodale, E. The Neuroscience Institute: Cognitive Symptoms of Depression, USA
www.medscape.com
3.World Health Organization, www.who.int
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