Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.
– World Health Organization
Depression
Edited by Bernard B. Tulsi
Guyana Journal, January 2010
Introduction
Major depressive disorder (MDD) - or depression - is a common mental health condition that affects more than 20% of all Americans (50 million people) during their lifetimes. About 10% or 25 million people suffer from depression at any given time in the United States. Women tend to develop the condition twice as often as men.
The management of depression costs about $83 billion a year (based on 2000 data). Only about a third of that goes to direct medical treatment: inpatient and outpatient care and pharmaceuticals. About 7% of the overall cost is for depression-related suicide issues, and almost two-thirds is attributable to lost productivity at work - absence and diminished performance.
While depression is well researched, documented and treated in North America and Western Europe, the condition is hardly confined to wealthy countries. In fact, depression is now ranked as the fourth leading cause of disability worldwide by the World Health Organization (WHO), which projects that in 10 years it will be exceeded only by ischemic heart disease.
To be sure, depression is especially problematic in poor developing countries - where social stigma is severe, cases are not always documented, treatments are not readily available, and trained staff and treatment facilities are scarce.
Differences in the availability of mental health personnel in rich and poor countries are shown in the following table”
| Mental Health Workers | Low-income countries (<$755/ year in annual income) | High-income countries (>$9,266/ year in annual income) |
| Psychiatrists | 0.05* | 10.50* |
| Psychologists | 0.04* | 14.00* |
| Social Workers | 0.04* | 15.70* |
*Median per 100,000 population
Precise data are not available, but migrants from poor countries to large metropolitan centers in North America and Europe appear vulnerable to depression. In many respects, migration may have alleviated life and death questions from their list of concerns; yet in their new situations immigrants often struggle with issues of separation and trying to adapt to their new cultures at the same time, which may cause them to become depressed.
What is depression?
Depression represents a deep level of distress that goes beyond feeling about difficult life experiences and tough circumstances, according to the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, (DSM IV), a publication of the American Psychiatric Association (APA). Patients have reported that their view of the world, their sense of self and how they perceive their own capabilities are all negatively affected by the condition. They feel hopeless about their lives and, worse, they believe that they are incapable of taking any steps to improve it.
Available evidence suggests that depression may be caused by both biological and environmental factors. Studies have demonstrated that first degree relatives (like your mother, father, sister or brother) of people with depression have a higher likelihood of getting the condition - supporting the role of biological factors (and a genetic component).
While it is not associated with mortality, depression has been linked to diminished quality-of-life - for patients as well as their families - pain, suicide and the worsening of several coexisting medical conditions.
Life circumstances and situational factors may cause or worsen depression. Examples of such factors may include:
o Premature parental loss
o Neglect of childhood emotional needs
o Traumatic childhood experiences
o Lack of a social support system
o Stress
o Illness (personal or of a loved one)
o Legal difficulties
o Financial struggles
o Employment problems
Symptoms
The depression syndrome occurs when symptoms of depression, accompanied by other signs, persist over time. Symptoms are both psychic (mental) and somatic (physical) and may affect feelings, thoughts and behaviors. Among them are:
o Depressed mood
o Feelings of sadness, emptiness, discouragement and hopelessness
o Irritability to a greater extent than sadness but with a strong sense of underlying unhappiness
o Uncontrollable crying
o Diminished enjoyment of life (anhedonia)
o Loss of interest in activities, hobbies, work and even relationships
o This may appear reasonable to the depressed person but hardly reflects an accurate assessment of his or her life
o Feelings of helplessness, hopelessness and low self esteem
o Strong sense that current problems are too severe and that the depressed person does not have the means to deal with them
o In severe cases, depressed patients may internalize the view that they are terrible people who have acted wrongly
o Diminished energy
o Persistent feelings of tiredness and lack of energy
o Changes in activity levels
o Slowed movements and/or slowed speech
o Alternatively, feelings of agitation, inability to sit still, constant wringing of hands
o Sleep alteration
o Insomnia
o Difficulty falling asleep, tossing and turning
o Awakening after a few hours and unable to go back to sleep
o Excessive sleep (less likely)
o Dietary changes
o Feeling that once favorite foods have lost their taste
o Diminished appetite
o If patient eats less, there is significant weight loss
o If patient eats more (less likely) there is excessive weight gain
o Impaired ability to think
o Reduced concentration, poor memory, inability to make decisions
o Psychotic thoughts
o Patients may
o Hear voices (hallucinations) that criticize them for presumed failures
o Experience negative delusional beliefs, such as a malfunctioning body
o Suicidal ideation
o Patients with severe depression may think that the only way out is death
o As the condition worsens, patients may develop a specific suicide plan
o Suicidal thoughts are a sure sign that professional help is required
Treatment
The management of depression can either combine drug treatment (pharmacotherapy) with psychotherapy (talk therapy, cognitive behavioral therapy (CBT), group therapy) or can make use of them individually.
The most common medications used to treat depression today are the selective serotonin reuptake inhibitors or SSRIs. They act at serotonin receptor sites in the brain and have been shown to be as effective as and safer and more tolerable than earlier treatments such as the tricyclic antidepressants.
The serotonin and norepinephrine reuptake inhibitors (SNRIs) are another class of antidepressants with proven efficacy and acceptable safety profiles. These drugs act at both the serotonin and norepnephrine receptor sites in the brain and as a result are described as dual acting agents. Only three SNRIs are currently available on the market.
Other miscellaneous treatments are available as well, and are generally used when the circumstances indicate the need for a treatment switch, the need for additional medication (augmentation), or combination therapy. Alternative treatments currently available for the treatment of depression include extracts from plants such as Ginko biloba and St. John's Wort. These have not been subject to rigorous evaluations, and are generally used for the treatment of mild depression.
To be sure, there are a number of other acceptable treatment interventions. These include dietary changes, exercise regimens, light therapy, hospitalization and electroconvulsive therapy (shock treatment for severe depression).
Prognosis
Depression has a better prognosis than other mental health conditions because medication and psychotherapy, such as CBT, have been successful in alleviating the symptoms of the illness, according to the DSM IV. For many people, however, the disorder can be episodic and periodic stressors can cause a recurrence of symptoms. The chronic nature of depression suggests that an ongoing therapeutic relationship with an appropriate mental health professional is advisable.
Depression is a treatable disease. If you or someone you know is suffering from depression, please seek medical attention immediately.
For more information on depression, please visit:
Depression.com
The Depression Health Center's website at: http://www.webmd.com/depression/default.htm
The National Institute of Mental Health's website at: http://www.nimh.nih.gov/health/publications/depression/complete-index.shtml
Bernard B. Tulsi is a medical writer/consultant based in Newark/Delaware.
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