Depression is a common mental disorder that affects more than 280 million people in the world. Depression is felt as sadness, if it is in short duration, we call it sadness. Sadness is the commonest emotion felt by everyone. The sadness is called as depression when it is more pronounced in terms of duration, the longer the duration we call it as depression and also it should be pervasive that means most of the time in a month it should be the person feeling the sad, that means at the same time the quality and quantity of sadness should be very high and also the sadness should come in the way of functioning, especially affect job and any other social functioning we call it as depression .
Depression is a common and serious medical illness that negatively affects how you feel, the way you think and how you act. The three important domains of depression are Emotion, Cognition and Behavior.
Depression has three important triad, feelings of sadness, easy fatigability, loss of interest in the pleasurable activities you have once enjoyed. At the same time, Depression is a treatable medical condition. According to the mental health survey by NIMHANS, 2.7 % of the people suffering from depression. Lifetime prevalence 5% means if a hundred people live for 70 years five people have developed depression.2.7% prevalence means, at any given point of time, 2.7 % of the people are suffering from depression. These may be huge for our Indian population. Unfortunately, the treatment gap is 85% in India. That means only 15 people get treatment out of the hundreds of those who suffer from depression. If 3.6 Crore people are suffering, approximately 3 Crore people are not on treatment. That means three crore families are suffering due to depression.
WHO launched a global campaign in 2017 called “Depression: let’s talk” to raise awareness and encourage people to seek help. The campaign emphasized the importance of talking about depression as a vital component of recovery.
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What are the Challenges in Diagnosis of depression?
There are various challenges to diagnosis of depression. Depression can co-occur with other mental and physical diseases, which may complicate diagnosis and treatment. Stigma and discrimination around cultural sensitivity are also barriers to treating depression. A comprehensive assessment of a patient’s history, context and need is essential. There are no laboratory tests or imaging like M.R.I or C.T. scanning for the diagnosis of depression. The only way to diagnose depression is by doing a Clinical Examination, a mental status examination, an observation and a history- taking process. However, a multidisciplinary and culturally sensitive approach is needed to diagnose and treat depression.
What are the Challenges in treatment for Depression
Depression is widely undiagnosed and untreated because of
- Lack of insight and awareness of patients and their family members. Lack of knowledge in mental health, cultural and linguistic differences make some hindrance to treatment.
- Lack of access to treatment: Especially in low- and middle-income countries, there is a lack of trained healthcare professionals, resources and infrastructure.
- Stigma and discrimination: which may prevent people from seeking help or receiving adequate support from their family, friends and community.
- Inadequate mental health settings: Lack of resources and facilities in developing and underdeveloped countries worsen the condition of affected people.
What Researchers Say about Depression ?
Researchers say that depression is a complex and multifaceted mental disorder that affects millions of people worldwide. Depression is prevalent in medical settings not in psychiatry such as Cardiology, Oncology, Nephrology. Gastroenterology, Gynecology, Endocrinology, Neurology, Neurosurgery etc. In this chronic medical illness depression is highly prevalent and this condition increases mortality and also morbidity. However, if our medical settings are capable of diagnosing depression, the treatment rate and survival rate of patients might be increased.
Importance of Primary care units for diagnosing Depression.
Primary care units are important for diagnosing depression because they are often the first point of contact for people with mental health problems. Depression can be easily diagnosed and treated by primary health physicians in the community. There are various studies across the globe that say that by training the primary care physician we can diagnose and initiate the treatment. But the issue is the person accepting the treatment and continuing the treatment. Depression does not affect only the person and family but the whole society. Depression is the leading cause of mental health- related disease burden globally, affecting an estimated 30 crore (300 million) people worldwide.
What are the burdens behind undiagnosed depression?
Undiagnosed depression may have consequences for individuals, family and society.
- Impaired functioning and productivity
Imagine 30 crore people are in depression that means they are not productive and that causes a huge economic loss across the world.
- Reduced Quality of life and well-being.
People with undiagnosed depression may suffer their daily life with low self-esteem, hopelessness, guilt and worthlessness, agony, anxiety, fatigability, and suicidal thoughts.
- Huge health care loss in manpower and economy.
People with undiagnosed depression may visit various doctors for emergency, hospitalization and medication. If these doctors are not capable of diagnosing depression, they may give them various vitamins and injections and over- investigate them. This will cause a huge loss in terms of the manpower involved in treating them and giving them wrong treatment. It also causes economic loss.
- Increased Morbidity and mortality:
Depression also causes increased mortality and morbidity. A person with a chronic medical condition and depression may stop taking medication or refuse to adhere to the treatment. They may also refuse surgery or attempt suicide. This increases the mortality rate among people with depression. Moreover, studies have shown that depression has the highest morbidity rate worldwide. Among the ten leading causes of disability, depression ranks first.
According to a worldwide study in 2000, out of a hundred years lived, 9.4% of them will be with disability due to depression. Imagine if a person is diagnosed of depression, they will spend 9% of their life in depression.
What are the symptoms of Depression? (Diagnostic criteria)
According to the DSM-5, a person has major depressive disorder if they have Five or more of the following symptoms lasting for two weeks pervasively.
- Depressed mood most of the day, nearly every day
- Loss of interest or pleasure in all activities most of the day.
- Easy fatigability or loss of energy nearly every day
- Engaging in purposeless movements, such as paring the room, restlessness and so forth.
- Significant weight loss or gain, change in appetite nearly every day.
- Insomnia or hypersomnia nearly every day
- Feelings of worthlessness and excessive or inappropriate guilt nearly every day
- Diminished ability to think or concentrate or indecisiveness, nearly every day.
- Recurrent thought of death, recurrent suicidal ideation without a specific plan or a suicide attempt or a specific plan for committing suicide
The ICD-10 specifies different levels of severity for depressive episodes, based on the number of intensity of symptoms. These are termed as mild, have two or three symptoms and mild functional impairment.
Moderate, have four or more symptoms and moderate functional impairment.
Severe, have most or all symptoms, severe functional impairment with or without psychotic features.
How to differentiate depression from normal sadness?
Sadness is a normal human emotion that lasts for a very short time. It is temporary and usually triggered by something. When the situations change the intensity of hurt fades. In normal sadness you can easily return to a happy mood. A person with sadness talks to many people and responds quickly to the external stimuli.
Depression is a condition that means pervasive sadness. The severity of symptoms can last for more than two weeks, months or even years if left untreated. People with depression often suffer alone and have difficulties in their daily functioning. Depression affects their occupation, social functioning, family life, and biological functions.
Depression is a mental health disorder and can affect thinking, emotions, perceptions and behavior in a pervasive way.
What Causes Depression?
There are many causes for depression
Genetics is the one of the commonest causes of depression. Twin studies clearly said that there is a 30 % to 40 % chance of genetic vulnerability to depression. First- degree relatives have three to four times the risk of developing depression if their siblings or other family members have suffered from it. In the general population, the risk of developing depression is only 5%. If one of the parents has depression, the risk for their children is four times higher. That is 20%, that means genetics plays an important role.
Environmental factors also account for 60 % of the risk of developing depression. This means that the interplay of Genetics and environment is essential for the development of depression.
Various Biological theories have been developed to explain the causes and mechanism of depression.
- One of the factors involved in depression is the neural circuit that connects the Amygdala, the hippocampus and the prefrontal cortex.
- Another factor is the hypothalamic-pituitary-adrenal (HPA) axis which is part of the neuro-endocrine system. It causes increased cortisol levels, which contribute to depression.
- Hormonal dysfunctions, such as the development of hypothyroidism, can also lead to depression.
- Brain derived neurotrophic factors, which are important for neuronal survival and plasticity, also ended in depression.
- Finally Gut- Brain Axis, which is influenced by the microbiota, can affect mood and behavior.
Recent studies and research have revealed that gut-brain axis dysfunction is one of the important factors for the development of depression. The Gut microbiota communicates with the CNS through neural, endocrine and immune pathways. These microorganisms have direct effect on the neural system through serotonin, GABA, cytokines, tryptophan, butyrate, propionate and acetate.
Psychosocial factors of depression are prolonged stress, childhood adversity (abuse, maltreatment, bullying), disaster, war, trauma, substance or drug abuse, parental discord, relationship issues, chronic medical illness, certain jobs in the medical field and security forces, poverty etc.
Depression is an exceedingly a complex disorder, with similar cumulative etiologies, including genetic, epigenetic and environmental factors which together lead to the development of the disorder..
What are the health issues (comorbidity) along with Depression?
Comorbidity means having two or more health issues at the same time. Depression is often associated with other mental and physical disorders, which can make it more difficult to treat and manage.
Anxiety disorder also coexisted with depression; it is around 35-40%
Personality disorder also found along with depression; it is around 25-30%
Suicidal attempt or death by suicide is present in depressed person, it is around 10-20%
Chronic medical illnesses are also coexisted with them, it is 60-70%
Obsessive Compulsive Disorder (OCD) which involves unwanted and intrusive thoughts and behaviors. OCD affects about 10%of people with depression. Whenever a person is having depression, it is essential to check various co -morbidity including medical conditions.
Substance use such as alcohol or drug abuse affect about one-third of the people with depression..
Some of the most common physical disorders that co-occur with depression are:
Cardiovascular diseases such as hypertension, coronary artery disease or stroke.
Metabolic disorders such as diabetes, obesity etc.
Chronic pain such as back pain, arthritis or fibromyalgia
Neurological diseases such as multiple sclerosis, migraine and epilepsy.
What happens if depression is untreated?
If untreated, the depressed person starts substance abuse or drug use to overcome the difficulties of depression. It badly affects both his physical and mental health.
Disruption in family life, due to depression is very common. The person cannot go to work, and it affects the family’s smooth running and functioning. Economic, personal and marital issues are developed within the family. It has worsened the condition of the depressed person and the family members. They do not take responsibility because he always feels tired. Every person in the family is shouting at him and consider him as lazy. They abuse and bully him with words; thus, depression gets worse.
There is also a financial loss, job loss, disability or sometimes he is met with suicide. So, it is essential to be diagnosed and treated for depression as early as possible.
A person has any chronic medical illnesses along with depression, their treatment is very difficult, morbidity and mortality are high for the patient.
What are the treatment options for depression?
Various modalities are available for treatment
- Psychotherapy is suitable in the mild stage of depression. If it is a moderate stage, medication is also essential along with the psychotherapy.
- Psychoeducation is first choice of treatment, educate the family and the patient.
- Antidepressant Medication: These are drugs manage the levels of certain chemicals in brain such as Serotonin, dopamine and norepinephrine.
- Electro Convulsive Therapy: in severe depression along with suicidal ideation or attempt, it is preferable better for treatment.
- Transcranial magnetic stimulation
- Vagus nerve stimulation
- Deep brain stimulation etc.
- Theta-Burst stimulation (TBS)
- Magnetic seizure Therapy (MST)
- Ketamine