Depression is a significant contributor to the global burden of diseases and affects people in all communities across the world. Today, depression is estimated to affect 350 million people. The World Mental Health Survey conducted in 17 countries found that on average about 1 in 20 people reported having an episode of depression in the previous year.
A recent World Health Assembly called on the World Health Organization and its member states to take action in this direction. Depression is a common, treatable disorder which continues to remain under-detected in the primary care settings. A large majority of patients with depression present to physicians with complaints of medically unexplained somatic symptoms, or masked depression. Further, the rates of depressive disorders are higher among the chronic medically ill persons and in primary care patients.
Extent of depression
Recently conducted world mental health surveys indicate that major depression is experienced by 10-15% people in their lifetime and about 5% suffer from major depression in any given year. Lifetime prevalence of all depressive disorders taken together is over 20% that is one in five individuals.
In terms of public health significance, depression is the third leading cause of global disease burden, accounting for 4.3% of total disability-adjusted life years. If current trends continue, it will become the leading cause of disease burden by the year 2030.
What is depression?
Depression is a common mental disorder that presents with depressed mood, loss of interest or pleasure, decreased energy, feelings of guilt or low self-worth, disturbed sleep or appetite, and poor concentration. Moreover, depression often comes with symptoms of anxiety. These problems can become chronic or recurrent and lead to substantial impairments in an individual’s ability to take care of his or her everyday responsibilities.
At its worst, depression can lead to suicide. Almost 1 million lives are lost yearly due to suicide, which translates to 3000 suicide deaths every day. For every person who completes a suicide, 20 or more may attempt to end his or her life. There are multiple variations of depression that a person can suffer from, with the most general distinction being depression in people who have or do not have a history of manic episodes.
While depression is the leading cause of disability for both males and females, the burden of depression is 50 percent higher for females than males. In fact, depression is the leading cause of disease burden for women in both high-income and low-and middle-income countries. Research in developing countries suggests that maternal depression may be a risk factor for poor growth in young children. This risk factor could mean that maternal mental health in low-income countries may have a substantial influence on growth during childhood, with the effects of depression affecting not only this generation but also the next.
Reducing burden of depression
While the global burden of depression poses a substantial public health challenge, both at the social and economic levels as well as the clinical level, there are a number of well-defined and evidence based strategies that can effectively address or combat this burden. For common mental disorders such as depression being managed in primary care settings, the key interventions are treatment with generic antidepressant drugs and brief psychotherapy. Economic analysis has indicated that treating depression in primary care is feasible, affordable and cost-effective. The prevention of depression is an area that deserves attention.
Many prevention programs implemented across the lifespan have provided evidence on the reduction of elevated levels of depressive symptoms. Effective community approaches to prevent depression focus on several actions surrounding the strengthening of protective factors and the reduction of risk factors.
Examples of strengthening protective factors include school-based programs targeting cognitive, problem-solving and social skills of children and adolescents as well as exercise programs for the elderly. Interventions for parents of children with conduct problems aimed at improving parental psychosocial well-being by information provision and by training in behavioral childrearing strategies may reduce parental depressive symptoms, with improvements in children’s outcomes.
Depression : A real illness
Sadness is something we all experience. It is a normal reaction to difficult times in life and usually passes with a little time. When a person has depression, it interferes with daily life and normal functioning. It can cause pain for both the person with depression and those who care about him or her. Doctors call this condition “depressive disorder,” or “clinical depression.” It is a real illness. It is not a sign of a person’s weakness or a character flaw. You can’t “snap out of” clinical depression. Most people who experience depression need treatment to get better.
Signs and symptoms
Persistent sad, anxious, or “empty” mood; Feelings of hopelessness, pessimism ; Feelings of guilt, worthlessness, helplessness ; Loss of interest or pleasure in hobbies and activities ; Decreased energy, fatigue, being “slowed down”; Difficulty in concentration, remembering or making decisions ; Difficulty sleeping, early-morning awakening, or oversleeping ; Appetite and/or weight changes ; Thoughts of death or suicide, suicide attempts ; Restlessness, irritability ; and Persistent physical symptoms
Many factors may play a role in depression, including genetics, brain biology and chemistry, and life events such as trauma, loss of a loved one, a difficult relationship, an early childhood experience, or any stressful situation. Depression can happen at any age, but often begins in the teens or early 20s or 30s. Most chronic mood and anxiety disorders in adults begin as high levels of anxiety in children.
In fact, high levels of anxiety as a child could mean a higher risk of depression as an adult. Depression can co-occur with other serious medical illnesses such as diabetes, cancer, heart disease, and Parkinson’s disease. Depression can make these conditions worse and vice versa.
Sometimes medications taken for these illnesses may cause side effects that contribute to depression. A doctor experienced in treating these complicated illnesses can help work out the best treatment strategy. There are several types of depressive disorders:
Severe symptoms that interfere with the ability to work, sleep, study, eat, and enjoy life. An episode can occur only once in a person’s lifetime, but more often, a person has several episodes.
Persistent Depressive Disorder:
A depressed mood that lasts for at least 02 years. A person diagnosed with persistent depressive disorder may have episodes of major depression along with periods of less severe symptoms, but symptoms must last for 2 years.
Some forms of depression are slightly different, or they may develop under unique circumstances. They include: Psychotic depression, which occurs when a person has severe depression plus some form of psychosis, such as having disturbing false beliefs or a break with reality (delusions), or hearing or seeing upsetting things that others cannot hear or see (hallucinations).
much more serious than the “baby blues” that many women experience after giving birth, when hormonal and physical changes and the new responsibility of caring for a newborn can be overwhelming. It is estimated that 10 to 15% of women experience postpartum depression after giving birth.
Seasonal Affective Disorder (SAD):
which is characterized by the onset of depression during the winter months, when there is less natural sunlight. The depression generally lifts during spring and summer. SAD may be effectively treated with light therapy, but nearly half of those with SAD do not get better with light therapy alone. Antidepressant medication and psychotherapy can reduce SAD symptoms, either alone or in combination with light therapy.
Bipolar Disorder is different from depression. Someone with bipolar disorder may experience episodes of extreme low moods (depression). But a person with bipolar disorder also experiences extreme high moods (called “mania”).
Depression affects people in different ways
Not everyone who is depressed experiences every symptom. Some people experience only a few symptoms. Some people have many. The severity and frequency of symptoms, and how long they last, will vary depending on the individual and his or her particular illness. Symptoms may also vary depending on the stage of the illness.
Women with depression do not all experience the same symptoms. However, women with depression typically have symptoms of sadness, worthlessness, and guilt. Depression is more common among women than among men. Biological, lifecycle, hormonal, and psychosocial factors that are unique to women may be linked to their higher depression rate. For example, women are especially vulnerable to developing postpartum depression after giving birth, when hormonal and physical changes and the new responsibility of caring for a newborn can be overwhelming.
Men often experience depression differently than women. While women with depression are more likely to have feelings of sadness, worthlessness, and excessive guilt, men are more likely to be very tired, irritable, lose interest in once-pleasurable activities, and have difficulty sleeping. Men may turn to alcohol or drugs when they are depressed. They also may become frustrated, discouraged, irritable, angry, and sometimes abusive. Some men may throw themselves into their work to avoid talking about their depression with family or friends, or behave recklessly. And although more women attempt suicide, many more men die by suicide.
Before puberty, girls and boys are equally prone to develop depression. A child with depression may pretend to be sick, refuse to go to school, cling to a parent, or worry that a parent may die. Because normal behaviors vary from one childhood stage to another, it can be difficult to tell whether a child is just going through a temporary “phase” or is suffering from depression.
Sometimes the parents become worried about how the child’s behavior has changed, or a teacher mentions that “your child doesn’t seem to be himself.” In such a case, if a visit to the child’s pediatrician rules out physical symptoms, the doctor will probably suggest that the child be evaluated, preferably by a mental health professional who specializes in the treatment of children. Most chronic mood disorders, such as depression, begin as high levels of anxiety in children.
The teen years can be tough. Teens are forming an identity apart from their parents, grappling with gender issues and emerging sexuality, and making independent decisions for the first time in their lives. Occasional bad moods are to be expected, but depression is different.
Older children and teens with depression may sulk, get into trouble at school, be negative and irritable, and feel misunderstood. If you’re unsure if an adolescent in your life is depressed or just “being a teenager,” consider how long the symptoms have been present, how severe they are, and how different the teen is acting from his or her usual self. Teens with depression may also have other disorders such as anxiety, eating disorders, or substance abuse. They may also be at higher risk for suicide. Children and teenagers usually rely on parents, teachers, or other caregivers to recognize their suffering and get them the treatment they need.
Many teens don’t know where to go for mental health treatment or believe that treatment won’t help. Others don’t get help because they think depression symptoms may be just part of the typical stress of school or being a teen. Some teens worry what other people will think if they seek mental health care.
Depression often persists, recurs, and continues into adulthood, especially if left untreated. If you suspect a child or teenager in your life is suffering from depression, speak up right away.
Having depression for a long period of time is not a normal part of growing older. Most older adults feel satisfied with their lives, despite having more illnesses or physical problems. But depression in older adults may be difficult to recognize because they may show different, less obvious symptoms.
Sometimes older people who are depressed appear to feel tired, have trouble sleeping, or seem grumpy and irritable. Confusion or attention problems caused by depression can sometimes look like Alzheimer’s disease or other brain disorders. Older adults also may have more medical conditions such as heart disease, stroke, or cancer, which may cause depressive symptoms. Or they may be taking medications with side effects that contribute to depression.
Some older adults may experience what doctors call vascular depression, also called arteriosclerotic depression or subcortical ischemic depression. Vascular depression may result when blood vessels become less flexible and harden over time, becoming constricted. The hardening of vessels prevents normal blood flow to the body’s organs, including the brain.
Those with vascular depression may have or be at risk for heart disease or stroke. Sometimes it can be difficult to distinguish grief from major depression. Grief after loss of a loved one is a normal reaction and generally does not require professional mental health treatment.
However, grief that is complicated and lasts for a very long time following a loss may require treatment. Older adults who had depression when they were younger are more at risk for developing depression in late life than those who did not have the illness earlier in life.
Depression is treatable
Depression, even the most severe cases, can be treated. The earlier treatment begins, the more effective it is. Most adults see an improvement in their symptoms when treated with antidepressant drugs, talk therapy (psychotherapy), or a combination of both. If you think you may have depression, start by making an appointment to see your doctor or health care provider. This could be your primary doctor or a health provider who specializes in diagnosing and treating mental health conditions (psychologist or psychiatrist).
Certain medications, and some medical conditions, such as viruses or a thyroid disorder, can cause the same symptoms as depression. A doctor can rule out these possibilities by doing a physical exam, interview, and lab tests. If the doctor can find no medical condition that may be causing the depression, the next step is a psychological evaluation.
Talking to your doctor
How well you and your doctor talk to each other is one of the most important parts of getting good health care. But talking to your doctor isn’t always easy. It takes time and effort on your part as well as your doctor’s. To prepare for your appointment, make a list of: Any symptoms you’ve had, including any that may seem unrelated to the reason for your appointment; When did your symptoms start? ; How severe are your symptoms?; Have the symptoms occurred before? ; If the symptoms have occurred before, how were they treated? ; Key personal information, including any major stresses or recent life changes ; All medications, vitamins, or other supplements that you’re taking, including how much and how often; and Questions to ask your health provider.
If you don’t have a primary doctor or are not at ease with the one you currently see, now may be the time to find a new doctor. Whether you just moved to a new city, changed insurance providers, or had a bad experience with your doctor or medical staff, it is worthwhile to spend time finding a doctor you can trust.
Tests and diagnosis
Your doctor or health care provider will examine you and talk to you at the appointment. Your doctor may do a physical exam and ask questions about your health and symptoms. There are no lab tests that can specifically diagnose depression, but your doctor may also order some lab tests to rule out other conditions.
Ask questions if the doctor’s explanations or instructions are unclear, bring up problems even if the doctor doesn’t ask, and let the doctor know if you have concerns about a particular treatment or change in your daily life. Your doctor may refer you to a mental health professional, such as a psychiatrist, psychologist, social worker, or mental health counsellor, who should discuss with you any family history of depression or other mental disorder, and get a complete history of your symptoms. The mental health professional may also ask if you are using alcohol or drugs, and if you are thinking about death or suicide.
Depression is treated with medicines, talk therapy (where a person talks with a trained professional about his or her thoughts and feelings; sometimes called “psychotherapy”), or a combination of the two. Remember: No two people are affected the same way by depression. There is no “one-size-fits-all” for treatment. It may take some trial and error to find the treatment that works best for you.
Antidepressants are medicines that treat depression. They may help improve the way your brain uses certain chemicals that control mood or stress. There are several types of antidepressants: Selective serotonin reuptake inhibitors (SSRI); Serotonin and norepinephrine reuptake inhibitors (SNRI); Tricyclic antidepressants (TCA); and Monoamine oxidase inhibitors (MAOI)
There are other antidepressants that don’t fall into any of these categories and are considered unique, such as Mirtazapine and Bupropion. Although all antidepressants can cause side effects, some are more likely to cause certain side effects than others. You may need to try several different antidepressant medicines before finding the one that improves your symptoms and has side effects that you can manage.
Most antidepressants are generally safe, but the U.S. Food and Drug Administration (FDA) requires that all antidepressants carry black box warnings, the strictest warnings for prescriptions. In some cases, children, teenagers, and young adults under age 25 may experience an increase in suicidal thoughts or behavior when taking antidepressants, especially in the first few weeks after starting or when the dose is changed. The warning also says that patients of all ages taking antidepressants should be watched closely, especially during the first few weeks of treatment.
Are herbal medicines useful ?
You may have heard about an herbal medicine called St. John’s wort. St. John’s wort is an herb. Its flowers and leaves are used to make medicine. It is one of the top-selling botanical products in the United States. But St. John’s wort is not a proven therapy for depression. The FDA has not approved its use as an over-the- counter or prescription medicine for depression, and there are serious concerns about its safety and effectiveness.
Taking St. John’s wort can weaken many prescription medicines, such as: Antidepressants; Birth control pills; Cyclosporine, which prevents the body from rejecting transplanted organs; Digoxin, a heart medication; Some HIV drugs; Some cancer medications; and Medications used to thin the blood.
Talk therapy (Psychotherapy)
Several types of psychotherapy—or “talk therapy”—can help people with depression. There are several types of psychotherapies that may be effective in treating depression. Examples include cognitive-behavioral therapy, interpersonal therapy, and problem-solving therapy.
Cognitive Behavioral Therapy (CBT) can help an individual with depression change negative thinking. It can help you interpret your environment and interactions in a positive, realistic way. It may also help you recognize things that may be contributing to the depression and help you change behaviors that may be making the depression worse.
Interpersonal Therapy (IPT) is designed to help an individual understand and work through troubled relationships that may cause the depression or make it worse. When a behavior is causing problems, IPT may help you change the behavior. In IPT, you explore major issues that may add to your depression, such as grief, or times of upheaval or transition.
Problem Solving Therapy (PST) can improve an individual’s ability to cope with stressful life experiences. It is an effective treatment option, particularly for older adults with depression. Using a step-by-step process, you identify problems and come up with realistic solutions. It is a short-term therapy and may be conducted in an individual or group format. For mild to moderate depression, psychotherapy may be the best option.
However, for severe depression or for certain people, psychotherapy may not be enough. For teens, a combination of medication and psychotherapy may be the most effective approach to treating major depression and reducing the chances of it coming back. Another study looking at depression treatment among older adults found that people who responded to initial treatment of medication and IPT were less likely to have recurring depression if they continued their combination treatment for at least 2 years.
Electroconvulsive therapy and other brain stimulation therapies
If medications do not reduce the symptoms of depression, electroconvulsive therapy (ECT) may be an option to explore. There are a lot of outdated beliefs about ECT, but here are the facts:
Some people believe that ECT is painful or that you can feel the electrical impulses. This is not true. Before ECT begins, a patient is put under brief anesthesia and given a muscle relaxant. He or she sleeps through the treatment and does not consciously feel the electrical impulses.
Within an hour after the treatment session, which takes only a few minutes, the patient is awake and alert. Other more recently introduced types of brain stimulation therapies used to treat severe depression include Repetitive Transcranial Magnetic Stimulation (RTMS) and vagus nerve stimulation (VNS).
In 2008, the FDA approved RTMS as a treatment for major depression for patients who have not responded to at least one antidepressant medication. In 2005, the FDA approved VNS for use in treating depression in certain circumstances—if the illness has lasted 2 years or more, if it is severe or recurrent, and if the depression has not eased after trying at least four other treatments. VNS is less commonly used, and more research is needed to test its effectiveness.
If you have depression, you may feel exhausted, helpless, and hopeless. It may be extremely difficult to take any action to help yourself. But as you begin to recognize your depression and begin treatment, you will start to feel better. Here are other tips that may help you or a loved one during treatment: Try to be active and exercise. Go to a movie, a ballgame, or another event or activity that you once enjoyed; Set realistic goals for yourself; Break up large tasks into small ones, set some priorities, and do what you can as you can; Try to spend time with other people and confide in a trusted friend or relative. Try not to isolate yourself and let others help you; Expect your mood to improve gradually, not immediately.
Do not expect to suddenly “snap out of” your depression. Often during treatment for depression, sleep and appetite will begin to improve before your depressed mood lifts; Postpone important decisions, such as getting married or divorced or changing jobs, until you feel better. Discuss decisions with others who know you well and have a more objective view of your situation; Remember that positive thinking will replace negative thoughts as your depression responds to treatment and Continue to educate yourself about depression.
You are not alone
Major depressive disorder is one of the most common mental disorders in the society. You are not alone. Sometimes living with depression can seem overwhelming, so build a support system for yourself. Your family and friends are a great place to start.
Talk to trusted family members or friends to help them understand how you are feeling and that you are following your doctor’s recommendations to treat your depression. In addition to your treatment, you could also join a support group.
These are not psychotherapy groups, but some may find the added support helpful. At the meetings, people share experiences, feelings, information, and coping strategies for living with depression. Remember, always check with your doctor before taking any medical advice that you hear in your group. If unsure where to start, talk to someone you trust who has experience in mental health—for example, a doctor, nurse, social worker, or religious counsellor.
Some health insurance providers may also have listings of hospitals offering support groups for depression. Remember, joining a support group does not replace your doctor or your treatment prescribed by your doctor. If a support group member makes a suggestion that you are interested in trying, talk to your doctor first. Do not assume what worked for the other person will work for you.
If you know someone who is depressed, it affects you too. The most important thing you can do is to help your friend or relative get a diagnosis and treatment. You may need to make an appointment and go with him or her to see the doctor. Encourage your loved one to stay in treatment or to seek different treatment options if no improvement occurs after 06 to 08 weeks.