Everybody's mood varies according to events in the world around them.
People are happy when they achieve something or saddened when they fail a
test or lose something. When they are sad, some people say they are
'depressed', but the clinical depressions that are seen by doctors differ
from the low mood brought on by everyday setbacks. Psychiatrists see a
range of more severe mood disturbances and so find it easier to
distinguish these from the normal variations of mood seen in the
community. General practitioners (GP's) need to be sensitive enough to
distinguish emotional reactions to setbacks in life from anxiety
syndromes, somatisation and clinical depressions. The general idea is
that anxiety disorders, depressive episodes, somatisation and adjustment
reactions are all different entities, but in practice it is not always
that clear-cut. Major depression, as defined by psychiatrists, is
unfortunately relatively common. What is depression? The term "affect"
refers to one's mood or "spirits." "Affective disorder" refers to changes
in mood that occur during an episode of illness marked by extreme sadness
(depression) or excitement (mania) or both. Depression is a disorder of
affect. Affective disorders are predominantly disturbances of mood that
are severe in nature and persistent despite the influence of external
events. Depression is characterized by severe and persistent low mood,
which is often unresponsive to the efforts of friends and family to cheer
the sufferer up. Patients who suffer with repeated episodes of depression
have a Recurrent Depressive Disorder. Depressive episodes can be
classified into mild, moderate, and severe types, with or without
psychotic symptoms. To be classified as depression, an episode must last
more than two weeks. A condition where the mood is persistently low, but
does not quite fulfill all the criteria for a depressive episode, is
sometimes called "dysthymia." Community studies have found that
depression is prevalent between 5 and 20% of all people. About 10% of
people over age 65 will have a major depressive episode. The incidence of
depression is higher in women and in urban settings rather than rural
settings. Clinical features of depression Mild depressive episodes
typically include features such as: ?Sadness and crying, ?Loss of
interest in and loss of enjoyment of life (anhedonia), ?Poor attention
and concentration, ?Low self-esteem and ideas of unworthiness, ?A bleak
view of the future and the world in general, ?Poor sleep and appetite.
People with mild depressive episodes find it difficult to continue with
their work and social lives, but usually continue to function, although
less than normal. Moderate depressive episodes have a wider range of
symptoms, which are present usually to a greater degree. Sufferers find it
very difficult to function normally at work or home. Severe depressive
episodes typically may also include features such as: ?Great distress and
agitation, ?Slowed thought and movement (psychomotor retardation),
?Ideas of guilt, ?Suicidal fantasies or plans which may be acted upon,
?Pronounced somatic symptoms, ?Psychotic symptoms. People with severe
depressive episodes find it impossible to continue with their work,
domestic and social lives, and usually cease to function in these areas.
Depression is often accompanied by slowing of thought processes and
biological features of everyday life which differ from a normal sense of
sadness. Crying is a frequent symptom, although some individuals are
reluctant to admit this, and others feel so depressed it that is as if
they have 'gone beyond crying'. Suicidal ideas occur in most depressed
people, and asking about these is a crucial aspect of their assessment.
Depressed patients often find it a relief to talk about these ideas with
their doctor. Asking about suicidal ideas is a sequential process,
beginning with questions about the severity of the low mood. The doctor
can then ask if the patient has ever felt that life is not worth living.
A 'yes' could be followed by inquiring whether the patient has ever felt
like ending their own life. Finally the doctor needs to assess if the
patient has any particular plans in mind. Case History: Janet Janet
Gordon was aged 35 when she lost her job as a manager of a department
store. At first she looked on her period of unemployment as an
opportunity to try out activities she had previously no time for. She
went hill-walking and painting every day. Two months later she had lost
interest in these things and was despairing that she would never work
again, although she had an exemplary work record. Her sleep at night was
poor and she had started going to bed during the day. Janet cried almost
daily and had lost interest in the food she cooked. All food tasted
bland, she said to her mother (who was concerned when she saw how much
weight Janet had lost). At her mother's suggestion Janet went to her
family doctor where she complained about how tired she always felt. She
asked for some sleeping tablets to help her sleep at night. Case
History: Alan Alan Benson was brought to the accident and emergency
department by his son. Alan had tried to hang himself from the banisters
at the family home. Fortunately the clothes' line that he had chosen to
hang himself with had broken under his weight. When he was seen by the
psychiatrist Alan had a red weal mark around his throat from the noose. He
was staring at a fixed point on the floor. Now and then he would groan
deeply and whisper to himself. He kept repeating the words 'I'm for
it..I'm for it now.' He would not make eye contact with the doctor and
initially refused to answer questions. His son said that the previous
week his father had stopped going to work as a bailiff after he found out
that his wife was having an affair. He had watched her obsessively for two
days, not letting her out of his sight. Then a few days ago he had taken
to his bed, and lain there for hours and hours not moving, not speaking,
not eating and not drinking. He had talked about how everything was his
fault and had at times been pleading with an unseen person to forgive
him. He felt that he had committed some unpardonable crime and that he
should now be punished. Armed with this information the psychiatrist
talked to Mr. Benson again. This time Mr. Benson replied, even if only
briefly. He said that God was telling him that his wife had to find
another man because her husband had been so evil. He confessed that he had
once had an affair himself many years before, and that God had told him
in the last week that He had punished Mr. Benson with syphilis. His wife
could be spared from the syphilis only if he killed himself. Once he was
dead, he thought, his wife could begin a clean life with another man.
Differential Diagnosis Many physical disorders can be present with
depressive illness. They include: hypothyroidism, hyperthyroidism,
Addison's disease, Cushing's disease, electrolyte disturbances,
alcoholism, drug abuse, carcinoma and dietary deficiencies (B12, B1, and
folic acid). Various drugs can cause depression. Psychological disorders
that may mimic depression include adjustment reactions, anorexia nervosa,
bulimia nervosa, anxiety disorders, substance abuse, obsessive-compulsive
disorder, dysthymia, seasonal affective disorder, and abnormal bereavement
reactions. Panic disorder commonly co-exists with or pre-dates
depression, (Andrade et al, 1994). Diagnosing and treating underlying
physical causes must be attempted and are key factors in the correct
prognosis of the actual cause of a persons depression. Risk factors for
depression ?In Young Adults: ?Urban dwellers, ?Unemployment,
?Physical ill-health, ?Previous affective illness, ?Family history of
depression, ?Childhood abuse/trauma, ?Loss of mother before age 11,
?Looking after several young children, ?No confidence, ?Bereavement. In
Older People: ?Bereavement of a close figure in last six months,
?Loneliness (but not living alone), ?Lack of Satisfaction with Life,
?Female Sex. The risk factors for older people identified above have some
predictive value in identifying people at risk of depression three years
later. Life satisfaction and bereavement help predict recurrences of
depressive illness. The higher prevalence of depression amongst women
could be because women are more prone to depressive illness biologically
or because of their social roles, or could be because male depression is
under-recognized, or incorrectly labeled. However, suicide is more common
among men than women. It is worth remembering that only 50% of depressed
patients who present to their GP are correctly diagnosed as suffering
with depression. Most depressed people in the community do not receive
treatment. Over 90% of depressed elderly people in the community suffer
without treatment. Armed with knowledge of its prevalence, causes and
common features, one might assume that it is a simple task to diagnose
depression in general practice settings. Unfortunately it isn't.
Certainly having a high index of suspicion and a professional willingness
to consider the possibility of depression are important factors in our
ability to diagnose depression. Additionally patients also have a
significant part to play in enabling - or preventing us - from arriving at
a diagnosis of depression. It is rare to find depression as a simple,
unitary diagnosis in general practice. It is much more common for
patients to show a combination of problems - some physical, others social
- within which depression can all to easily be either unnoticed, or
assumed to be inevitable and therefore untreatable. Freeling et al [1985]
and Tylee et al [1993] have shown that severe depression is much more
likely to be missed if associated with significant physical illness.
Moreover, many patients have strong reservations about disclosing
depression to their GPs. Depression itself often contains feelings of
hopelessness and despair. Patients may therefore feel that there is no
point in talking to the doctor about it since there is nothing that they
or anybody else can do about it. These negative perspectives can be
compounded by GPs - often unwittingly - if they give the impression of
rushing through their consultations and being unable or unwilling to sit
and listen to our patients' concerns. There is still a considerable
stigma attached to mental illness. Many people have a great fear of the
consequences of acknowledging their depression to a professional person:
they may be 'carted off to a loony bin', or written off as 'mad'. If the
word 'depression' appears in medical notes they fear - often correctly -
that this will be prejudicial to future employment or insurance
prospects. Fear of antidepressant medication is also a very important
obstacle to disclosure of depression. A study undertaken by the Defeat
Depression campaign showed that many people confuse antidepressants with
benzodiazepines, and are genuinely worried about becoming dependent -
'getting hooked' on them, and about unpleasant effects of withdrawal.
There is considerable public skepticism about the effectiveness of
antidepressants. Most patients would prefer to be offered counseling
rather than drugs, but doubt if they will be given such a choice by their
GP. Faced with this complex barrage of obstacles, it is perhaps
surprising that we ever do manage to make a diagnosis of depression!
However, there are many things that can be done to increase the chances of
detection. We need to help some patients to reattribute physical symptoms
to psychological causes. If a patient is feeling tired all the time, has
no energy or interest in life and is sleeping very badly, these chances of
their being depressed are very high. Often a direct question - 'do you
think you may be depressed?' - is all that is needed to move the
consultation onto a psychological agenda. Sometimes it is better to take
a more indirect route. The word 'stress' is a very useful bridge, since
it intrinsically has both physical and mental components: 'Are under any
extra or unusual stress at the moment?', or 'Do you think these symptoms
might be due to stress?' are effective open ended questions. For those
few patients who appear reluctant to consider any diagnosis of depression
it may initially be most profitable to concentrate on its more physical
manifestations - sleep and appetite disturbance, or energy loss - without
forcing the issue of their underlying causation. We must also accept
patients' genuine anxieties about the shame attached to depression, and
acknowledge their concerns about the harmful effects of drug therapies.
Good basic consultation skills include inquiry into patients' expectations
and fears about the nature and consequences of their problems. This will
take us a long way towards understanding not only whether our patients
are depressed, but the context and meaning that their depression has for
them. Many people experience enormous relief when their problems are
explored in this way. To a large extent, therefore, effective diagnosis
is also the most crucial aspect of effective treatment. Management
There are two important dimensions to be considered in deciding how best
to manage depression in general practice. First, mild depression may
often be managed effectively through sympathetic exploration of the
factors precipitating it - whether physical illness, a recent personal
crisis in work or relationships - and encouragement of the patient's own
coping mechanisms and supportive informal social networks. Moderate and
severe depression have been shown to respond to antidepressant drug
therapy. As we have seen it is essential to discuss patients' anxieties
and expectations of drug treatment before starting it. Also, drugs should
be viewed as complementary rather than alternative to talking about
depression. Problem-solving is a useful and simple skill to develop.
The first stage is the creation of a problem list. This is something
usually best done by the patient between sessions, although they may need
some help initially. The patient writes down a list of problems which he
is experiencing at present, either in terms of how he feels - miserable,
tired, bored etc. - or in terms of things he is unable to do - go to
work, enjoy hobbies, etc. He can then rank these problems in order of
importance, and set goals for overcoming them. These goals should be
staged and not too ambitious. For instance, if feeling bored is a central
concern, it might be useful to discuss which aspects of life give the
most pleasure and interest - watching TV soaps, walking the dog, having a
bath, and agreeing that the patient will spend a set amount of time each
day doing just that. Problem-solving works well in conjunction with drug
therapy, and directly addresses the sense of hopelessness that is central
to depression. It enables both doctor and patient to achieve a sense of
purpose and direction, and provides a practical means ofmonitoring and
demonstrating progress. The second dimension to the management of
depression in general practice concerns the views and experience of the
doctor and the patient. GPs vary considerably in their skills, experience
and confidence in dealing with depression. Some of us will prefer to
refer early to other professional colleagues, whether counselors,
psychologists or psychiatrists, while others are more comfortable about
managing even acute and severe problems. Patients, as we have seen, may
also have strong views about the causes, effects and treatment of
depression. If we are to manage it effectively we must take these into
account. When people feel they are being listened to, and have genuine
choices about what happens to them - whether they receive counseling or
drug therapy or both, whether they are referred for psychiatric opinion
or not - they are more likely to be committed to the management plan that
emerges. Many patients, even when expressing suicidal thoughts, may prefer
to be managed at home by their GP than be admitted to a psychiatric ward:
the problem then becomes one for us, in assessing the degree of risk and
responsibility that we feel able to sustain. It is worth remembering
that, involving our patients in genuine decision-making about the
management of their illness is intrinsically therapeutic. Studies of
treatments versus placebo have endorsed the value of physical therapies
such as ECT (electric-convulsive treatment or "shock therapy") in severe
depression and antidepressants in mild, moderate and severe depression.
Most depressive illnesses respond to such treatments. Tricyclic
antidepressants need to be taken regularly in adequate doses for an
adequate length of time. Inadequate doses of Tricyclic antidepressant are
linked to suicidal behavior in some studies. Newer antidepressants (SSRIs
and RIMAs) offer a relative safety in overdose. Some psychological
treatments have proven efficacy, notably cognitive-behavioral therapy and
interpersonal psychotherapy for mild and moderate depression. Their
drawbacks are that they take longer to have an effect and are not
well-standardized. There is evidence that cognitive behavioral therapy
and interpersonal psychotherapy may help maintain health when combined
with antidepressant medication, but there is as yet little evidence to
suggest that counseling alone is a suitable treatment for major
depression. Where there is evidence of continued relationship or family
difficulties psychotherapy may be particularly useful. Cases of moderate
to severe depression may need vigorous treatment by a community
psychiatric team and close follow-up to help prevent relapse and improve
prognosis. Severely depressed patients with or without psychotic symptoms
require inpatient admission and may respond best to electro-convulsive
treatment. Who to refer people to: Counselors, psychotherapists,
community psychiatric nurses, occupational therapists, social workers and
psychologists, unless also medically qualified, are not trained to
diagnose depression, recognize its origin, or formulate long-term
management plans. If referring on to one of these agencies as the sole
provider of psychological care, the onus is on the general practitioner
to diagnose the depression correctly, to be certain about its origin and
to have a clear long-term management protocol in mind. The General
practitioner must therefore be sure to have excluded physical illness as
a cause of the depression before referring on to the non- medically
trained. Prognosis The long-term prognosis for depression is still
guarded, however. Up to 15% of patients who have had depression will go
on to kill themselves. Recurrent episodes of depression are the norm
rather than the exception. Long-term studies of lithium suggest that it
may help to reduce the number of episodes and prevent suicide. Studies of
long-term use of antidepressants suggest beneficial effects. Long-term
efficacy of psychotherapy and counseling has not been proven. Learning
points: depression ?Depressive illness affects 10-18% of the adult
population. ?Depressive illness in the community is largely untreated,
because patients generally do not seek medical help, and of those
that do seek help only about 60% of those that see their family
doctor are recognized by them as suffering from depression. ?Depressive
illness is treatable - over 80% of cases can be resolved with adequate
treatment. ?Treatment may include antidepressants, (SSRIs, tricyclics,
MIRA drugs, or MAOIs), ECT (for severe or delusional depression) or
psychotherapy for mild to moderate depression (particularly
cognitive therapy).