The symptoms of depression can be divided into psychological and somatic. Psychological symptoms include persistent lowering of mood, with low self-esteem, pessimism, a sense of despair, hopelessness and helplessness, thoughts of suicide and irrational ideas of guilt and self-reproach. The somatic (biological) symptoms include loss of drive and energy. There is impairment of concentration, appetite, sleep and sex drive. Some patients eat excessively (‘comfort eating’).
There is also loss of a sense of enjoyment (‘anhedonia’). The patient’s mood may be significantly worse in the morning and improve somewhat as the day goes on (diurnal variation). The depression is classified as being of psychotic intensity when the patient experiences auditory hallucinations (typically making critical accusations) or has delusions of guilt. A formal diagnosis of depression requires the presence of the majority of the non-psychotic symptoms. However, patients may present with a somatic symptom such as backache and they themselves may not recognise that in fact they are suffering from a depressive illness.
Box 11.2 lists the symptoms that may appear in both depression and anxiety states.
Prevalance
The point prevalence of depressive illness is about 3% of men and up to 9% of women, with a lifetime risk in the general population of up to 12%
for men and 26% for women. Nearly 1% of the population is at risk of bipolar affective disorder (manic–depressive disorder). Genetic factors predispose to mood disorders, as shown by the high rates of the more severe types of disorder in first-degree relatives of people with depression.
Risk factors
Social factors are of great importance as precipitants of depressive illness.
Major adverse life events increase the risk of depression sixfold in the six months after the event. Other risk factors for depressive episodes, especially those following life events, include the loss of a parent before the age of 11 years and the lack of a confiding relationship with a partner.
Depression and alcohol misuse
Some patients with a primary depressive illness medicate themselves with alcohol. Conversely, alcoholics may go through bouts of depression that are precipitated by adverse changes in their social circumstances, while depression (and anxiety) can also occur during alcohol withdrawal (see Chapter 12 for a detailed description of the symptoms of alcohol dependence and withdrawal).
Depression and bereavement
Factors that increase the risk of developing a morbid or protracted grief reaction include death of a child or of a spouse, death that is sudden, unexpected, untimely or violent, and death for which the survivor feels responsible. Individuals are more at risk of pathological or protracted grief if they had an ambivalent or unduly dependent relationship with the deceased, if they have a history of mental health problems, if their family is perceived as unhelpful, or if there are other concurrent major adverse life events. When the relationship with the deceased has been ambivalent or full of conflict, feelings of guilt and anger complicate the course of grieving.
Box 11.2 Symptoms common to both anxiety and depression Impaired concentration
Insomnia Loss of weight Loss of libido
Non-specific physical symptoms, for example muscle tension Irritability
Undue preoccupation with health Fatigue
LIPSEDGE & SAMUEL
Those patients who develop a frank depressive illness may need an antidepressant. Antidepressants are also useful for patients who develop panic disorder as one of the psychiatric sequelae of bereavement. The voluntary organisation CRUSE is an invaluable counselling resource for the bereaved. Murray Parkes and Markus (1998), in a chapter on bereavement in adult life, provide helpful guidelines on understanding and helping people who have been bereaved.
The assessment of depression
The assessment of depression always requires an assessment of suicide risk (see below).
When investigating a first episode of depression it is important to look for a link between depression and physical illness or its treatment:
• corticosteroids and antihypertensive drugs, especially reserpine, methyldopa and levodopa, can cause depression
• depression can be a reaction to painful or potentially life-threatening physical disorders
• the symptoms of some physical illnesses, especially myxoedema (apathy, general slowing down, sluggishness, poor memory), resemble depression, and at yimes thyrotoxicosis, hyperparathyroidism and systemic lupus erythematosis can also present as depression
• depression may be a complication of other illnesses, for instance Parkinson’s disease and Cushing’s syndrome; it may also follow a viral infection, such as infectious mononucleosis and hepatitis.
Dysthymia
Dysthymia is a chronic depression of mood which does not fulfil the criteria of recurrent depressive disorder. Most of the time sufferers feel tired and miserable, although there are periods of days or weeks when they feel well and in general they can cope with the basic demands of everyday life. Dysthymia is commoner in women than in men and in the first-degree biological relatives of patients with a history of depressive episodes. Patients may benefit from antidepressants or cognitive therapy (see below).
Diagnostic tools
Beck Depression Inventory
This is a widely used self-rating inventory of proven validity, reliability and sensitivity to change. It comprises 21 items, each describing a specific behavioural manifestation of depression. Completion of the inventory results in a total score (maximum 63), which is a measure of the depth of depression (Beck et al, 1988a).
Beck Anxiety Inventory
This is a 21-item self-report inventory for measuring the severity of anxiety. It is recognised as a reliable and valid measure of anxiety which has high internal consistency and test–retest reliability as well as good concurrent and discriminant validity (Beck et al, 1988b).
Hospital Anxiety and Depression Scale
This scale, devised by Zigmond & Snaith (1983), comprises 14 items. It was designed specifically for use in non-psychiatric hospital depart-ments. The items on the scale are all concerned with the psychological symptoms of neurosis, thus making it suitable for use in patients with concurrent physical illness and disabilities.
Treatment of depression
Psychological treatment
Patients with depression have a negative attitude to themselves, to the world around them and to their future. Cognitive therapy consists of the identification of negative autonomic thoughts and training the patient to challenge these distortions. Examples of distorted thinking include:
• selective abstraction (‘I have not achieved my targets, so I am a useless employee’)
• arbitrary inference (‘my job must be at risk because my boss appeared angry with me today’).
In mild to moderate depression, cognitive therapy is as effective as an antidepressant and it can also help to prevent further episodes of depression. A course of cognitive therapy consists of 12–20 sessions, each of one hour. The therapist elicits habitual distortions in thinking, teaches the patient to challenge these maladaptive thoughts and thus alter the processing of information which has been perpetuating the depressed mood. Cognitive therapy helps patients to modify the negative expectations, assumptions, rules and schemata that determine their view of themselves and their relationships.
Case 11.4 Major depression
A 40-year-old computer engineer presented with symptoms of depression.
He had resigned from several jobs in the past while feeling like this and these episodes, which lasted from three to six months, recurred at three-yearly intervals. During these episodes he became preoccupied both professionally and personally with feelings of inadequacy. Despite a first-class university degree, he felt he was too slow to take in existing programmes and felt ill equipped on the technical side.
He described all the features of the ‘impostor complex’: he believed he had been overpromoted and was concerned that he would be exposed as a fraud;
as a result he considered resigning.
LIPSEDGE & SAMUEL
He was treated with lofepramine and underwent cognitive therapy with a clinical psychologist to teach him ways of restoring his self-confidence as well as reassessing his skills to reinforce his capabilities. He made steady progress and, despite one minor relapse when he stopped the antidepressant prematurely, he is now off medication and is a much-valued employee.
Pharmacological treatment
In severe depression, antidepressants which potentiate both serotonin and noradrenaline transmission are the most effective (e.g. venlafaxine).
In less severe depression, the tricyclics and SSRIs appear to be equally effective. All types of antidepressant have a latent interval of two weeks before the onset of a significant antidepressant effect, although the anti-anxiety effect (e.g. with a sedative tricyclic antidepressant such as dothiepin) is observed much earlier. Patients should be warned about the possibility of side-effects (e.g. dry mouth, constipation, drowsiness and postural hypotension with tricyclic antidepressants). They should also be told that the drugs are not addictive and that they must not expect an immediate response since recovery may take a matter of weeks. This should increase compliance.
Reasons for apparent treatment failure with antidepressants include starting at too high a dose, which causes intolerable side-effects and loss of compliance. Conversely, there is also a tendency to prescribe inadequate doses. The full therapeutic dose of tricyclics is at least 125 mg daily. The SSRIs may be better tolerated than tricyclic antidepressants and are safer when driving or using moving machinery.
In apparently treatment-resistant depression, the dose of antidepres-sants should be pushed up to the limits of tolerance and lithium can be used as an augmentor. The most severe cases of depression, including those of psychotic intensity, require electroconvulsive therapy (ECT).
The antidepressant should be continued for six months after recovery because about half the patients will relapse if the drug is stopped prematurely. Up to three-quarters of patients who have had an episode of major depression will suffer a relapse within ten years and perhaps 20% of patients with very severe depression become chronically depressed. The long-term administration of antidepressants can be helpful in preventing recurrent relapses.
Adverse effects of antidepressants
The adverse effects are brought about by blockade of post-synaptic neurotransmitter receptors. Tricyclic antidepressants block muscarinic, histamine and alpha1-adrenoreceptors and can therefore cause:
• drowsiness and slowing of cognition
• dry mouth
• constipation
• weight gain
• tachycardia
• postural hypotension (and in overdose they can cause cardiac arrhythmias)
• dysuria
• erectile dysfunction
• blurred vision
Lofepramine is a modified tricyclic antidepressant which mainly affects noradrenaline uptake and it is relatively well tolerated.
The SSRIs block only serotonin reuptake. Common side-effects include:
• nausea
• anxiety
• insomnia
• erectile difficulties
• delayed orgasm.
Although venlafaxine blocks both noradrenaline and serotonin re-uptake, its adverse effect profile is like that of the SSRIs.