CAUSATION As with other types of psychiatric illness, it is usual for a case of
depression to be caused by several subsidiary causes, acting together. This has well been expressed by NICE (4):ì
The enormous variation in the presentation, course and outcomes of depressive illnesses is reflected in the breadth of theoretical explanations for their aetiology, including genetic, biochemical and endocrine, psychological and social processes and/or factorsÖmost now believe that all these factors influence an individualís vulnerability to depression, although it is likely that for different people living in different circumstances, precisely how these factors interact and influence that vulnerability will vary between individuals..î
The various factors which have been linked to depression in research
studies include the following:
HEREDITY There
is no doubt that depression runs in families sometimes. Research
comparing monozygotic (identical) twins with (nonidentical) dizygotic
twins has proved that there is a genetic component to this tendency.
If one identical twin has bipolar affective disorder, then the co-twin will also develop it about 60% of cases. In non-identical twins, the risk is about 20%. The only possible explanation for this difference is closer degree of genetic relation. Hence, this difference is proof of a genetic component in bipolar affective disorder.
However,
it will be noted that even in identical twins, the concordance rate is
not 100%, showing the importance of nongenetic, that is environmental,
factors.
In general, it can be said that if an index patient has a mood disorder, of any kind, then their relatives are at higher risk than the general population of also having a mood disorder of any kind. The lifetime risk of illness in relatives of affected patients is about 10-20% in first-degree relatives.
The more severe the disorder in the index patient, the more likely is it that there will be relatives also affected.
The pattern of inheritance is polygenic, that is, small contributions from many genes, rather than just one defectve gene. Much effort is going into the molecular genetic approach to this; however clear conclusions as regards aetiology are still awaited.
BRAIN BIOCHEMSITRY Much
effort has gone into the field of the biochemistry of the brain in
depression. This effort is based on the view of the brain as made up of
billions of individual cells called neurones. The main way that the
neurones communicate with each other, which is thought to be the basis
of the function of the brain, is through the release of small packets
of chemicals (neurotransmitters) that interact with ìreceptorsî on
neighbouring neurones.
Neurotransmitters are a variety of
different chemical substances, some of them related to adrenaline, such
as serotonin. Drugs which have been found to be helpful in depression
often have actions in increasing or decreasing neurotransmission, for
example the so-called selective serotonin reuptake inhibitors, SSRIs,
increase the availability of serotonin.
However, other drugs
which affect other neurotransmitters such as noradrenaline also are
effective antidepressants, and simplistic theories of depression as a
chemical imbalance (ìyour stores of serotonin are running outî) are
incompatible with the complexity of the various neurotransmitters and
various receptors for them, as delineated by the psychopharmacologists.
It
seems likely that the neurochemical disturbance in depression is the
route by which the depression is produced, rather than the ultimate
origin of it.
HORMONES Deficiency of thyroid hormone or hormones from the adrenal gland is well recognised as a cause of depression.
More
subtle changes in hormones have been proposed as the cause of
depression, for example to do with the response to stress of the
adrenal gland. However, these have not led to major advances in
treatment, or even understanding of the condition.
SOCIO-ECONOMIC FACTORS In
clinical practice, and in medicolegal work, the predominant impression
is of depression being linked to adverse life circumstances and to
things that happen.
The NICE guidelines go so far as to refer (page 18) to the ìsocial origins of depression,î and reference a
study
showing that up to 50% of the difference between the rates of
depression in neighbouring general practices could be explained by
differing unemployment, poverty and related factors.
As well
as long-term social difficulties, is a well-established body of
evidence indicating that patients with depression have experienced more
adverse ìlife eventsî than people without depression. These events,
particularly so-called ìloss eventsî, appeared to be the precipitant of
the majority of episodes of diagnosed depression.
Such ìevents,
dear boy, eventsî, usually combine with the above-mentioned long-term
difficulties, which include not only material poverty, but also absence
of confiding relationships and family/social support, to produce the
depressive episode.
Hence, the medicolegal debate about the
causation of an episode of depression following an accident, and the
possible contribution of previously existing factors such as social
adversity, can be seen to have sound underpinnings in this social
sciences research on depression causation.
PSYCHOLOGICAL FACTORS There
is research which substantiates the clinical experience that patients
with depression frequently have had an adverse experiences in
childhood, especially inadequate parenting or loss of a parent,
especially the mother.
This may lead to lack of confidence and
low self-esteem as an adult, making the person more likely to have a
depressive episode when they encounter, as we all inevitably do,
adverse events.
The cognitive theory of depression was
popularised by Beck. It proposes that depression is caused by the
person repeatedly and automatically thinking negative thoughts. For
example, they may ìrun themselves down,î or put everything that happens
to them in the worst possible light. The corollary is that depression
could be treated by training the person to think positive thoughts, and
there is indeed evidence that such training, in the form of cognitive
therapy, can be effective.
PERSONALITY It
is probable that the effects of genetic loading, adversity in childhood
and psychological factors such as negative thinking come together in
forming a particular type of personality, which have a higher risk than
the average of going on to develop depressive illness.
Such
personality ties will include anxious or dependent types, those who
have long-term difficulties in coping with stress and people with
constitutional tendencies to gloom, sometimes referred to as dysthymia.
Obsessional personalities can find it particularly difficult to adapt
to stress or life changes, and this can ìcome outî as depression.
There are frequent exceptions to these general rules, and it is important to appreciate that patients in the throes of a depressive or manic episode may give distorted accounts of their previous personalities.
Another postulated mechanism is that depression results from an inability to express hostility and aggression, so that these emotions are directed inwardly to produce self-blame and guilt. The learned helplessness model postulates that depression results from repeated failure to overcome problems by personal effort.
SOCIAL STRESS: depressed patients report more ìlife eventsî, especially loss events, than general population controls during the few months before their illness onset. About 80% of depressive episodes appear to be precipitated by life event stress. Chronic social difficulties, lack of confiding relationships and absence of a supportive social network are important mediating factors.
The effect of life events is strongest in respect of first episodes of depression. In subsequent episodes, the effect of life events is less (this is sometimes referred to as ìkindlingî).
In patients where there is a strong genetic component, the reduction in the importance of life events is seen early in the course of the illness (ì
pre-kindlingî); in cases where there was a lesser genetic component, the reduction in the effect of life events occurred more gradually (5).
In other words, patients can reach a state in which they are vulnerable to the occurrence of further episodes of depression in the absence of life events, either because of genetic vulnerability or because of the cumulative effects of previous depressive episodes.
There is also evidence that some social factors, such as the presence of a confiding relationship, can be protective.
CAUSATION: SUMMARY In conclusion, there is evidence that individuals may be vulnerable to the development of episodes of depression, and that this vulnerability can be made up of genetic, psychological, personality and social factors (which probably overlap with each other in fundamental origin). The episode is precipitated by life events in most cases, but the role of life events may be less in cases which are recurrent and/or strongly familial.
CLINICAL FEATURES The following description covers the key aspects of depressive illness
in everyday clinical and medicolegal practice in my view. These
features can conveniently be thought of as either mental or physical.
MENTAL FEATURES OF DEPRESSION The
cardinal symptom of a depressive illness is of course depression of
mood. This must go beyond the everyday experience of, for example, ìIím
really depressed about the gas bill.î There are those in psychiatry who
feel that depression can be diagnosed without depression of mood being
obvious to the patient or readily apparent to the psychiatrist.
It
is possible that this may apply to prodromal or very mild cases of
depression. However, the majority in psychiatry, would I think agree
that depression of mood would be present in almost all cases of
significant depressive illness.
Hence, if depression is
diagnosed in a medicolegal report, there does need to be a proper
description of the mood. The essential feature is that
there must be a pervasive depression of mood,
that is, the mood must be low in respect of all aspects of the personís
life, though not necessarily to the same extent throughout. There must
also be
loss of enjoyment of things the patient used to take pleasure in, so-called anhedonia.
If
these features were not present, then the proponent of a diagnosis of
depression would be on a sticky wicket. However, it would not be
impossible that he would be able to pull it off, at any rate to the
extent of a mild depressive condition, with the aid of associated
symptoms.
In a true depressive illness, the patient has a
negative view of himself, so that he feels
guilty, that he is a failure or a bad person. This will tend to be coupled with
pessimism or
hopelessness.
Accordingly,
a diagnosis of depression cannot generally be based solely on anger or
irritability or hostility. Depression of mood, and negative view of
self should generally be present, I believe, in the eyes of most
practising clinical psychiatrists.
In any clinically significant depressive illness, the patientís i
ntellectual function will be affected.
Perhaps because of lack of drive or preoccupation with negative ideas
or both, the ability to concentrate will be reduced. This means that
work becomes harder and takes longer; not infrequently, patients
believe that they are losing their memory, whereas what in fact is
happening is that they are not remembering things in the first place
because they are not able to concentrate properly.
As with other mental disorders, the
risk of suicide must be assessed. Patients often feel that ìit would be better if I was not aroundî, or that ìI wish I was deadî.
It is important to gauge whether the patient has gone beyond this, and has an active
plan to
kill himself. Thoughts of how they might do it are not uncommon as
their subject of depressive rumination; patients can have prominent
thoughts about methods of suicide, yet nevertheless give realistic, and
apparently reliable assurances that they would not do this because of,
for example, family responsibilities.
In severe depressive states, the patient may become
psychotic. That is, they may
delusions and hallucinations (psychotic symptoms).
Typical
depressive delusions would be an unshakeable conviction is that the
person is guilty of some dreadful crime, or their bowels have turned to
stone or other hypochondriacal preoccupation.
Typical
hallucinations in psychotic depression would be a voice addressing them
(second person), saying for example. ìYou are a bad person, you deserve
to die.î
What
are sometimes referred to as ì
biologicalî symptoms of depression are important
because, in clinical practice in psychiatry, they are taken as a
marker- not the only marker, but an important one- of a clinically
significant depressive illness.
Disturbance of sleep and appetite are the most frequent.
Sleep disturbances include d
ifficulty
in getting off to sleep, so-called ìinitial insomniaî, disturbed sleep
with frequent wakening, and early-morning wakening. This last is
a classic symptom of a depressive illness, and is often coupled with
diurnal mood variation: that is, the patient wakes up early in the
morning with a very depressed mood, which is then at its lowest point
of the 24-hours. During the day, the mood gradually brightens as the
patient gets going.
Traditional teaching has this pattern as
indicative of an endogenous depressive illness, that is one coming from
within the patient, in contrast to an exogenous or reactive depression
due to external causes, where the sleep disturbances were said to be
more in the nature of initial insomnia. Unfortunately, research has not
borne out these intuitively attractive patterns, and the
endogenous/reactive classification of depressive illnesses is no longer
regarded as useful for therapeutic or prognostic purposes- though
obviously it remains an important aspect of the medicolegal assessment
in respect of causation.
Classically, a depressive illness is accompanied by
loss of appetite and loss of weight.
Sometimes, however, especially in milder state of depression, there may
just be a loss of interest in food with little change in weight;
ìcomfort eatingî of junk and other food, with weight increase, is
common also.
Core symptoms of depression include
pain and tiredness.
These have been recognised since the early days of psychiatry. (Indeed,
a more insightful way of looking at the problem would be to retreat
from the somewhat arbitrary mind/body split in which, at any rate in
western societies, we view the experience of distress.)
PAIN AND FATIGUE AND DEPRESSED MOOD can be thought of as an army which marches together, or at any rate, a platoon;
often, the depressed mood is the most prominent feature and the correct
clinical diagnosis of a depressive illness is easily made.
Sometimes
however, if the patient feels reticent about their emotional distress,
the pain or the tiredness may be presented as the main problem. There
is good evidence that depression of mood is the underlying problem in
many patients given otherwise mystifying labels of ìchronic fatigue
syndromeî or ìchronic pain syndromeî.
There may be effects on physical activity, with unwanted excessive movement ñ
agitation- or marked reduction of activity, so-called
retardation, where the patient may take to bed or chair and become physically slowed down. This may progress to depressive stupor. Older patients may show marked intellectual impairment (depressive pseudodementia).
Other physical symptoms include
constipation
or diarrhoea, disturbances of the menstrual cycle including cessation
of the menstrual periods (amenorrhoea), loss of energy and loss of
interest in sex (loss of libido).
PHYSICAL (SOMATIC, BIOLOGICAL, VEGETATIVE) SYMPTOMS are just as common as psychological ones and often form the presenting complaint when depressed patients consult in general practice.
Sleep is nearly always disturbed. Some patients wake early and cannot go back to sleep. This early morning waking is often linked with diurnal variation, with mood lowest on waking, followed by a lifting of mood as the day goes on; both these symptoms are strongly suggestive of depressive illness.
Other patients have difficulty in getting off to sleep, and some sleep longer than usual but find their sleep unrefreshing.
Appetite is usually reduced, with consequent weight loss. A few patients eat more, and gain weight.
Other somatic symptoms include constipation, amenorrhea, impotence, pain in various sites including head, face and back, fatigue and general malaise.
CLASSIFICATION OF DEPRESSIVE ILLNESS This
is a complex and controversial area.
The word ìdepressionî covers a wide range of conditions, from transient unhappiness to life-threatening psychiatric illness.
Various theories about types of depression (see
below) have had to be abandoned, The current approach is atheoretical.
ICD 10 just lists the symptoms as follows:
ìIn typical mild,
moderate, or severe depressive episodes, the patient suffers from
lowering of mood, reduction of energy, and decrease in activity.
Capacity for enjoyment, interest, and concentration is reduced, and
marked tiredness after even minimum effort is common. Sleep is usually
disturbed and appetite diminished. Self-esteem and self-confidence are
almost always reduced and, even in the mild form, some ideas of guilt
or worthlessness are often present. The lowered mood varies little from
day to day, is unresponsive to circumstances and may be accompanied by
so-called "somatic" symptoms, such as loss of interest and pleasurable
feelings, waking in the morning several hours before the usual time,
depression worst in the morning, marked psychomotor retardation,
agitation, loss of appetite, weight loss, and loss of libido.î
CLASSIFICATION OF DEPRESSIVE ILLNESS IN ICD Depression in the ICD is just graded as mild, moderate or severe ì..depending upon the number and severity of the symptoms..
F32.0
Mild depressive episode Two
or three of the above symptoms are usually present. The patient is
usually distressed by these but will probably be able to continue with
most activities.
F32.1
Moderate depressive episode Four
or more of the above symptoms are usually present and the patient is
likely to have great difficulty in continuing with ordinary activities.
F32.2
Severe depressive episode without psychotic symptoms An
episode of depression in which several of the above symptoms are marked
and distressing, typically loss of self-esteem and ideas of
worthlessness or guilt. Suicidal thoughts and acts are common and a
number of "somatic" symptoms are usually present.
F32.3
Severe depressive episode with psychotic symptoms An
episode of depression as described in F32.2, but with the presence of
hallucinations, delusions, psychomotor retardation, or stupor so severe
that ordinary social activities are impossible; there may be danger to
life from suicide, dehydration, or starvationÖî
The severe
states of depression, described above, are usually obvious to all
concerned. They tend to respond well to physical methods of treatment
such as antidepressant medication or, in an emergency,
electroconvulsive therapy (ECT ).
However, the milder types of
depression, give rise to greater divergences professional opinion and
greater controversy therefore.
There are obvious problems with the practical use of ICD in daily clinical psychiatry, however. For example, there is no minimum time period. If one takes the description, literally, a person who has a brief episode of say ì..decrease in activity..and .. marked tiredness after even minimum effort..î and who is able to ì..to continue with most activities..î would nevertheless be diagnosable with a mild depressive episode by one psychiatrist.
Another
psychiatrist, however, might suggest that, in his professional opinion,
on balance, the patient was very far from fulfilling criteria for the
diagnosis of a depressive illness.
DSM IV is slightly more rigourous, in that it does at least require, for a diagnosis of ìmajor depressionî:
- a two week minimum period
- 5 symptoms out of 9 (see list below)
- at least one of the symptoms is either depressed mood or loss of interest or pleasure.
However, this continues to set the bar very low, and to contain a very wide potential diversity amongst different patients with the same diagnosis. DSM symptoms are:
1 depressed mood, most of the day, nearly every day
2 diminished interest or pleasure in all or almost all activities most of the day, nearly every day
3 significant weight loss when not dieting or weight gain
4 insomnia or hypersomnia nearly every day
5 agitation or retardation
6 fatigue or loss of energy
7 worthlessness or inappropriate guilt
8 reduced ability to think or concentrate
9 thoughts of death, or suicidal ideation or plan
There is much more common ground between the subtype of major depression denoted ìmelancholiaî in DSM IV, and the ìsevere depressive episodeî of ICD 10. Patients with these diagnoses have a condition, which has always been recognised by psychiatrists. It is the much larger numbers of milder cases where the potential for disagreement is greater.
DYSTHYMIA is a long-term state of low mood. It probably reflects inbuilt
personality characteristics; there is evidence, however that it does
respond partially to long-term antidepressant medication, especially
during periods of worsening of symptoms.
ENDOGENOUS/ REACTIVE DEPRESSION is
a classification of depressive illness is, which is now regarded as
simplistic. It sets up a false dichotomy between environmental and
personal factors, whereas in fact research indicates that both genetic
and other inherent factors interact with the occurrence of "life
events" to produce the depressive illness in most cases.
SEASONAL AFFECTIVE DISORDER (SAD) is
a condition where the patient becomes depressed during the long hours
of darkness in the winter months. Associated features include lethargy,
disturbed sleep including excessive sleeping, and disturbed appetite
including weight gain.
The condition was proposed
comparatively recently, as a separate entity, the appropriate treatment
being light therapy. However, it appears that the illness is in fact,
fundamentally a type of depression, where the seasonal factors are part
of the causative process. The illness response to standard treatment
for depression in the usual way and is not generally regarded as an
inherently separate illness from depression.
CLINICAL CLASSIFICATION OF DEPRESSION The authors of the International classifications emphasise that they have to be interpreted by the experienced clinician. Their inherent problems in respect of depression have been alluded to briefly above. I therefore now proceed to give a clinical guide to depressive illness.
Severe depression is characterised by a pervasive depression of mood, which has a different quality from ordinary sadness, cannot be expressed by tears even if the patient wants to cry, and is unrelated to external circumstances. Somatic symptoms (early morning waking, diurnal variation of mood, anorexia, weight loss) are often prominent, and psychotic features (delusions and/or hallucinations) may be present. Severe episodes usually respond best to physical methods of treatment (see below) rather than psychological therapies alone.
Mild depression is more common, and the symptoms more like an exaggeration of ordinary unhappiness. Somatic symptoms are not prominent, and delusions and hallucinations do not occur. There may be marked tearfulness, anxiety, irritability, and difficulty getting to sleep.
It is however a grossly overdiagnosed condition, especially in general practice; this is not to criticise colleagues in primary care, but it is a frequent experience for psychiatrist to be referred patients who have been diagnosed and treated for depression, but who have never had the condition.
The key point is the mood; the patient has to have a true depression of mood, that is persistent low mood unrelieved by circumstances; if this is not present, then depression is not present either. A natural reaction, or an adjustment disorder, or dysthymia are more likely alternatives.
ENDOGENOUS AND REACTIVE DEPRESSION is another rather outdated distinction based on whether or not a precipitating life stress predating the depressive episode can be identified. Most depressive episodes are at least in part ìreactiveî, in which case resolving the external stress and/or helping the patient cope with it more constructively should certainly be part of management. But it is important to consider biological treatments if symptoms of severe depression are present, however understandable the cause. For example, drug treatment can be helpful for depressive illness following life events such as bereavement (Ch 6), or in medically ill patients (Ch 11) including those with terminal disease.
The term
psychotic depression, which is self explanatory, is sometimes used, but the converse term of neurotic depression has largely been dropped because of the pejorative overtones of the word ìneuroticî.
SEASONAL AFFECTIVE DISORDER (SAD) is a condition in which depressed mood accompanied by lethargy, excess sleep, increased appetite and irritability recurs each winter. It was believed to respond exclusively to light treatment; however recent studies indicate it can be just as effectively managed with standard methods such as medication.
MASKED DEPRESSION describes cases presenting with somatic symptoms when the patient denies depressed mood and may even appear cheerful and smiling. Self-evidently, this would be an unusual clinical situation requiring careful assessment; the term as depression is not unanimously accepted.
DIAGNOSIS OF DEPRESSIVE ILLNESS The
diagnosis of depressive illness in clinical settings will have some
regard to the official classifications set out above. However, clinical
training and experience also comes into play.
Mild reactions to
difficulties experienced in life may not in practice be diagnosed as
clinical depression. The clinician may in practice look for features
such as biological symptoms of depression, anhedonia and guilt before
entertaining the diagnosis.
Most episodes of depression are brief and mild, and dealt with by the
patientís own resources, or talking with a relative or friend. Of those
patients who do present to doctors, the vast majority is dealt with in
primary care.
The diagnosis of depressive illness in clinical settings will have some
regard to the official classifications set out above. However, clinical
training and experience also comes into play.
Also, it must be borne in mind that
the international classifications such as ICD and DSM were not designed
for medico-legal use, and have not been validated in these settings.
Hence, too much reliance cannot be placed upon them, especially in
circumstances where there is controversy about the presence or absence
of a diagnosable condition, with the patientís problems at the milder
end of the spectrum.
Depressed mood which seems unduly severe or prolonged in relation to its apparent cause, the presence of somatic symptoms, or prominent guilt, pessimism, anhedonia, suicidal thinking and low self-esteem all suggest depressive illness.
RATING SCALES exist to permit quantitative measurement of the severity of depressed mood. Their main use is in research work, for example comparing response to different treatments. They may be used clinically as screening instruments to help detect depression in high-risk populations, for example patients attending general hospitals.
Observer-rating scales include the Hamilton and MontgomeryñAsberg.
Self-rating scales include the Beck, Zung, Carroll, Wakefield, Leeds and HAD (Hospital Anxiety and Depression) Scales.
DIFFERENTIAL DIAGNOSIS OF MOOD DISORDERS: SYMPTOM OR DIAGNOSIS It
is important to remember that depression of mood is just a symptoms- which can be due to a alrge number of medical or psychiatric conditions. Accordingly, depression should not
be accepted as the primary diagnosis until the possibility of an
underlying medical or psychiatric condition as the explanation for the
symptoms has been excluded.
Medical conditions: depression can be an integral part of the symptomatology of some medical conditions, including neurological disorders such as Parkinsonís disease, dementia, multiple sclerosis, anaemia; endocrine disorders such as hypothyroidism; virus infections such as influenza, and vitamin deficiencies such as vitamins B12 or folate.
Drug reactions: drugs which may precipitate depression include antihypertensives, especially reserpine and methyldopa, corticosteroids and possibly sex hormones, L-Dopa, digitalis, certain cytotoxics, certain antimalarials, sulphonamides and antipsychotics. Cholesterol-lowering drugs are also implicated.
Psychiatric conditions: depressed mood often accompanies other psychiatric disorders. In elderly patients, distinguishing between depressive illness and dementia is a common dilemma, though sometimes they are present together. Both depressive and manic symptoms may occur in combination with symptoms of schizophrenia: schizoaffective disorder. Agitated depression, and mixed depressive/anxiety neurosis, are easily mistaken for pure anxiety states. Antisocial personality disorder may be confused with mania.
substance misuse commonly coexists with depression; depression of mood can be secondary to alcoholism, due to the depressing effects of alcohol on the brain. Equally, patients with depression not infrequently attempt to self medicate with alcohol; this is counterproductive, however, because the euphoriant effects of alcohol only last an hour or two, and are followed by a superadded lowering of the mood. Hence, all psychiatric assessments must include a record of the patient's pattern of substance use.
TREATMENT OF DEPRESSIVE ILLNESS Most depressive episodes present in general practice, and quickly resolve with primary care treatment. It is likely that this represents a combination of the natural tendency of such conditions to resolve spontaneously, together with the positive effects of a sympathetic interview, diagnosis, explanation and reassurance.
The prescription of medication or the use of counselling is also likely be helpful, though in both cases the non-specific effects of treatment (so-called ìplacebo effectsî) are likely to be just as, if not more, important than the specific clinical effectiveness of the particular treatment employed.
Only a small percentage of such cases are referred to specialists, a figure of 10% would probably be on the high side. The majority of these are managed as outpatients; some of the more severe cases would be allocated help from the community mental health team, such as a community psychiatric nurse or attendance at a day centre.
Hospital admission may be required for patients who are suicidal, or refusing food and drink. Compulsory admission under the Mental Health Act 1983 may be required.
A few cases will need to have electroconvulsive therapy (ECT). ECT is a widely feared treatment, though it is very effective in emergency cases when the patient has for example stopped eating and drinking properly, and is in danger of death through dehydration. However, modern treatments seem to be increasingly effective and I prescribe it only about once a year in my practice. It is now either an emergency treatment, or a treatment of last resort.
NICE GUIDELINE This effectively advocates a ìstepped careî approach. It advocates screening, though it is
disputed that this would meet UK criteria for screening programmes. Watchful waiting, that is review in 2 weeks, is advocated for mild cases, and seems sensible. "Guided self-help" and "short-term psychological treatment" for mild and moderate cases are probably less realistic, however, due to lack of availability of same.
Prescription of an SSRI is the advocated next step, which aroused some controversy, but was essentially preaching to the choir. SSRIs and subsequent drugs have effectively taken over in primary care; few GPs would now start with a tricylcic, let alone an MAOI. For initial presentation of severe depression, treatment-resistant depression, recurrent depression, a combination of CBT and medication is suggested, but this again seems a council of perfection, in view of the limited availability thereof.
The guideline contains disappointingly little on the Community Mental Health Team. The encouragement of such professionals is in practice much more available, and probably more suitable for rehabilitation of chronic patients who need help with practical matters such as benefits and return to work.
Regarding ECT, NICE suggests that it is ìused only to achieve rapid and short-term improvement of severe symptoms after an adequate trial of other treatment options has proven ineffective, and/or when the condition is considered to be potentially life-threatening, in individuals with a severe depressive illnessî, which seems reasonable.
However, it comes down against maintenance ECT, the practice of giving a periodical application say once per month in order to try to prevent recurrence in chronic severe depressive illness. This practice, rare in adult psychiatry, is not uncommon in elderly psychiatry, where the frail older patient may experience fewer side-effects from ECT than from medication. This particular recommendation of NICE has therefore caused controversy.
MEDICATION AND PSYCHOLOGICAL TREATMENT would be the main specific therapeutic options.
However,
it is usually the case that no individual treatment is 100% effective;
a good recovery in a more severe case will often involve two or three
therapeutic modalities, such as medication and psychological treatment,
each contributing a partial amount, but adding up in combination to an
effective treatment package.
MEDICATION Antidepressant medication is probably the most frequently used
treatment for depression.
The main types of antidepressants are tricyclic antidepressants,
specific serotonin reuptake inhibitors (SSRIs) and monoamine oxidase
inhibitors (MAOIs).
The SSRI drugs are widely used in general practice,
where they are often associated with a good outcome. However, they are
probably weaker drugs in more severe depressive states; by the time the
patient has been referred to secondary care, they have probably already
failed to improve on SSRIs.
There is no logic in switching from one drug to another in the same category, as the similarities between them far outweigh the differences. Therefore, there is a strong case for the use of the previous generation of antidepressant drugs, such as the tricyclics (for example amitriptyline) in such patients. The tricyclics may have more side-effects, but are probably more powerful.
The
key point with medication is that it must be continued. Standard advice
is for the patient to continue with the medication until they are fully
recovered, and then for a further six months. At this stage, if the
patient has remained well, the possibility of a dose reduction can be
considered.
Many patients unfortunately stop medication soon as they feel rather better; this is often followed by quick return of symptoms, and the patient may then come to feel that the condition is incurable, and that the medication is ineffective. However, the truth is the exact opposite: the drug probably is effective, and the condition probably is responsive to the drug; the symptoms were therefore probably not have recurred if the patient had carried on with the medication.
- tricyclic antidepressants such as amitriptyline and imipramine have long been regarded by psychiatrists as the standard first line of treatment for depressive illness; they are probably the most effective drugs for severe depression. They are effective in about 70% of depressed patients
- SSRIs such as fluoxetine and paroxetine are now considered by some psychiatrists and many GPs to be the treatment of first choice, because they are safer in overdose than tricyclics and may have fewer side-effects. Others consider that SSRIs, which are more expensive, should be reserved for patients who cannot take tricyclics or have failed to respond to them.
- monoamine oxidase inhibitors (MAOIs) such as phenelzine and moclobemide are less often prescribed but sometimes dramatically effective when tricyclics have failed.
- lithium is mainly used in the prevention of recurrent affective disorder, but is also useful in an established depressive episode as adjunctive treatment to one of the antidepressants listed above.
A therapeutic trial of an antidepressant drug is often required when diagnostic doubt exists. Frequent changes of drug are to be avoided, and compliance needs checking. If and when an effective drug is found, it should be continued at least six months after recovery to reduce the risk of relapse, then gradually tapered off if the patient remains well.
ECT As previously indicated, ECT has a place in emergency treatment, and as a treatment of last resort. It is currently infrequently used, but tends to have good results in the more severe cases in which it is utilised these days. ECT is effective in about 80% of patients with severe depression, notably in psychotic cases with delusions or hallucinations. Mild depression seldom responds well to ECT.
Prescribing an antidepressant alongside ECT is usually recommended. Benzodiazepines, used for insomnia or anxiety, should be stopped before ECT is started, as their anticonvulsant properties will interfere with the effectiveness of ECT treatment.
PSYCHOLOGICAL TREATMENT A continuing supportive relationship with a trusted professional forms a valuable part of the treatment of all depressed patients.
Occupational therapy can also be most helpful in encouraging the patient to resume the full range of daily activities.
Cognitive therapy, designed to modify habitual negative thinking patterns which contribute to depressed mood, is as effective as drug treatment in moderate or mild depression. Interpersonal therapy, focused on relationships with others, is also useful.
Psychodynamic psychotherapy may perhaps be indicated for long term problems.
During a severe depression a purely psychotherapeutic approach is not appropriate because it will not correct delusions or hallucinations, and may increase patientsí feelings of guilt and unworthiness.
The various
types of counselling and other talking therapies are also discussed in the chapter concerned.
Occupational therapy can also be most helpful in encouraging the patient to resume the full range of daily activities.
RESISTANT DEPRESSION This term covers patients with significant depressive illness, who do
not seem to respond to standard treatment, or only respond partially.
Recovery, or at any rate improvement, is possible with continued
treatment in most cases. Combinations of medication, such as
anti-depressants with a small dose of a major tranquilliser or a mood
stabiliser will need to be tried in all probability.
PROGNOSIS The
outlook for the individual episode of depression is good. Up to 90%
will get better in surveys in clinical practice. The effect of
treatment is probably to bring forward the process of recovery, which
would probably have occurred naturally in many of these cases.
Prognosis
will be better in cases with favourable personality and circumstances
before the illness, where the illness is less severe and receives early
diagnosis and effective treatment. Older patients tend to do worse,
particularly if there are coexisting medical, social and economic
problems.
Even if their first episode has recovered, 70ñ80% of patients will suffer one or more further attacks at some stage in their lives. Some patients become ill at regular intervals, or at the same time each year.
The course for an individual patient is unpredictable.
