| bobwhelan 2004-08-27, 7:14 pm |
| Depressive disorders, which pose a substantial risk of death and
disability and are associated with suicide and poor work productivity,
affect about eight percent of adults. Moreover, close to twenty
percent of adults will suffer from some type of mood disorder that
requires treatment during their lifetime. Mood disorders often have
tragic results -- 15 percent of those affected commit suicide.
Depression, a common type of depressive disorder, is responsible for
about 66 percent of all suicides. The disease occurs twice as often in
women as in men and the risk increases if depression is present in an
immediate family member. As the leading cause of premature death and
disability in people between the ages of 18 and 44 years, it is
surprising that there are no universally accepted diagnostic criteria
for depression.
There are often errors in the diagnosis or treatment of the disease,
and only 33 percent of depressed patients receive proper treatment.
These errors are associated with insufficient questioning of the
patient leading to diagnostic failure; failure to receive adequate
information regarding the patients symptoms from family members;
diagnosing a mood disorder and starting treatment despite a lack of
diagnostic criteria; attempting to blame depression on stressful
events, rather than diagnosing or treating the disease.
One set of diagnostic criteria commonly used to assess depression is
known as "SIGECAPS" (see table below). This stands for sleep,
interest, guilt, energy, concentration, appetite, psychomotor and
suicide. If four or more of these items are a concern, it indicates
major depression. However, other criteria, such as watching for
symptoms other than just mood change and obtaining supporting
information from family members, is important.
Diagnostic criteria for major depressive disorder*
A. The patient has depressed mood (e.g., sad or empty feeling) or loss
of interest or pleasure most of the time for 2 or more weeks plus 4 or
more of hte following symptoms:
Sleep
Insomnia or hypersomnia nearly every day
Interest Markedly diminshed interest or pleasure in nearly all
activities most of the time
Guilt Excessive or inappropriate feelings of guilt or worthlessness
most of the time
Energy Loss of energy or fatigue most of the time
Concentration Diminished ability to think or concentrate;
indecisiveness most of the time
Appetite Increase or decrease in appetite
Psychomotor Observed psychomotor agitation/retardation
Suicide Recurrent thoughts of death/suicidal ideation
B. The symptoms do not meet crieteria for mixed episode (major
depressive episode and manic episode)
C. The symptoms cause clinically significant distress or impairment in
social, occupational, or other improtant areas of functioning
D. The symptoms are not due to the direct physiological effects of a
substance (e.g., a drug of abuse, a medication) or a general medical
condition
E.
The symptoms are not better accounted for by bereavement
*Adapted from the Diagnostic and Statistical Manual of Mental
Disorders, 4th edition.
The cause of depression is thought to be a disruption of the brain’s
neurochemistry. Central norepinephrine neural pathways in the brain
play a role in vigilance, motivation and energy levels. These pathways
are associated with serotonin neural pathways, which are involved in
controlling impulsivity, and share a role with the dopamine pathways
in appetite, sex and aggression.
Depression is expected to be the second leading cause of disability
for people of all ages by 2020. In general, an unhealthy lifestyle is
more common among those depressed than those who are not.
Additionally, children of those with depression are thought to have
increased rates of behavior problems and lower levels of self-esteem
than children with mothers who do not have depression.
In cases of moderate to severe major depression, antidepressant drugs
are often used for treatment. Typically, about 60 percent of patients
respond to the treatment, with the amount reaching 80 percent when a
second drug is tried if the initial antidepressant drug fails. The
goal of treatment is a full remission of symptoms, which may take up
to four months. Patient recovery is not linear, however, as symptoms
may reoccur after resolving.
Current guidelines suggest that antidepressant therapy should continue
for at least six months after recovery in order to lessen the chance
of a recurrence of depression, which occurs in more than 70 percent of
patients.
Maintenance therapy, using antidepressant therapy for an indefinite
amount of time, is considered as a treatment option for those who have
additional risk factors of depression, such as especially difficult
episodes or two or more episodes in a five-year period. The therapy’s
goal is to prevent recurrence of the illness, however, costs and side
effects of continued medication should be reviewed.
Another therapy, electroconvulsive therapy (ECT) is an effective
treatment for about 60 percent to 80 percent of depressed patients who
receive it. ECT is often used in patients who have psychotic features,
display active suicidal tendencies and do not respond to
antidepressant chemotherapy. The reason why ECT is effective remains
unclear, but the therapy is typically associated with a slowing in the
prefrontal cortex, which likely affects a fundamental neurobiologic
process. ECT is usually given in courses of 6 to 12 treatments, with
improvements usually occurring after the fourth treatment.
Phototherapy, or light therapy, is particularly used for fall/winter
seasonal depressions. Treatment, typically prescribed for mild to
moderate cases, consists of exposure to full-sprectrum white light for
at least 30 minutes per day throughout the episode.
Another treatment used for mild to moderate major depression is
psychological treatment. This type of intervention, including
interpersonal and cognitive behavioral therapies, has been found to be
as effective as antidepressant therapy. The treatment can be
administered individually or in a group setting and usually lasts for
8 to 16 weekly sessions.
Combined treatments, for example anti-depressants with psychological
treatment, are also used. The decision of which treatment to use
should be based on patient preference, advice from a clinician, cost,
practicality and success rates of different treatment types within an
individual patient.
Canadian Medical Journal November 26, 2002
--
bobwhelan
"Studies have found that after 3 months of antidepressant
treatment between 50% and 65% of the people who take them
will be much improved (see references). This compares
with 25 - 30% of people given an inactive "dummy" pill,
or placebo."
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