Determining depression

One in 5 people will experience an episode of depression during their lifetime, but only 1 in 3 will be diagnosed. Depression as an illness has been linked with high suicide rates and it can have a devastating impact. However, for those who slip through the holes in the system, the dangers go beyond the obvious. Symptoms of depression have been associated with everything from low salt levels in the elderly to pancreatic cancers and malignant brain tumours - which is why getting the diagnosis exactly right is very important, says Dr. Nirosha Mendis, Consultant Psychiatrist.

Just a bad mood?

"There is a distinction between clinical depression and feeling sad," says Dr. Mendis, explaining that the latter is self limiting. Clinical depression is recognizable by the severity and intensity of the symptoms and its longer time frame. Insomnia, excessive feelings of guilt or worthlessness, loss of concentration and focus, weight loss, suicidal tendencies, sexual problems and an accompanying loss of libido are only a few of the symptoms associated with depression; however, symptoms of depression can vary dramatically from individual to individual. "In Sri Lanka, for instance, patients frequently complain of numerous medically unexplained physical symptoms, such as, headaches, joint pains, palpitations, gastric discomfort etc."

The impact on the individual's life is likely to be noticeable, if not detrimental. Relationships with family and friends will suffer, as will their academic performance or work. For some, psychotic symptoms like hallucinations and delusions are possible.

Anyone, any time

While women are twice as more likely to experience depression than men, depression can overcome anyone at anytime.

Pregnancy for instance, can be a very difficult period. "If a mother is depressed after giving birth she might not believe that she is competent to look after the child or she might not have any desire to look after the child," says Dr. Mendis. In cases of psychotic depression, where an individual might become very paranoid and deluded, they might end up harming the child or themselves. Mothers with a history of depression are more likely to suffer from depression during their pregnancy, and after delivery - the latter is known as post-partum depression. "Many studies have shown that treating post-partum depression is obviously very, very important, not least because of the repercussions on the child's emotional development," says Dr. Mendis.

Children and young adults might find it difficult to juggle multiple commitments and perform in the often demanding environments of school and work. "They exert themselves a lot," says Dr. Mendis, explaining that external factors like more time spent on the road or at extra-curricular activities can mean that very little time is left over for relaxation. "The pressure to perform can take a huge toll on your body, and I think you can initially present with some symptoms consistent with stress that can lead to a full blown depressive episode with time," says Dr. Mendis. Some of these might include a deteriorating performance at school, headaches, stomach aches, tiredness and other vague physical complaints which appear to have no obvious cause, and they may become increasingly withdrawn and introverted.
Women going through menopause may experience deep depression and swing between bouts of irritability and tearfulness. Elderly people over 65 are also vulnerable, particularly when they make the shift from an active life into retirement. "A person who has been working throughout his or her life can find that after they leave the job they have no role and feel lost," says Dr. Mendis, adding that chronic illnesses, especially those conditions like arthritis and rheumatism that give rise to pain, can be particularly taxing. Diseases, such as heart conditions or respiratory problems, might further limit mobility, leaving patients feeling particularly helpless and isolated.

Substance abuse, alcohol dependence, and your body's reaction to certain medications can give rise to symptoms of depression, says Dr. Mendis. "Incidence among alcoholics is very high - 60-70% of people who drink excessively have symptoms of depression." Those recovering from viral infections like dengue and chikungunya can also experience symptoms of depression.

Not just a mind thing

Depression is a complex condition, and its causes are only more so. "Any illness is an interaction between genetics and environmental conditions," says Dr. Mendis, "but people with a genetic predisposition are more likely to suffer from depression if they are faced with these environmental stresses." While a traumatic or deeply upsetting event could trigger a depressive episode, it is just as likely that there will be no obvious cause for depression. "There is this idea amongst people that there needs to be some kind of trigger for someone to be depressed, but most patients will tell you in retrospect that 'there was nothing wrong, everything was going well, why is it that I developed this?'" Similarly, recovering from depression is about more than just pure will or positive thinking.

Dr. Mendis also makes the argument against considering depression a purely mental illness. "True enough - you can have problems regarding thought processes or motivation, and of course it does affect mental processes, but I don't think it's accurate to classify it as a mental illness solely," he adds. "The accurate thing is to say that this is a brain disease that affects mental processes." And much of it has its roots in the body's processes. Variations in the levels of neurotransmitters like serotonin, problems with the receptors that deal with anxiety and abnormalities in brain blood flow can trigger depression. Even simple stress has its own physiological basis - "your body can start producing various chemicals that are toxic to the brain, like cortizol or adrenaline and these in turn can trigger this complicated imbalance."

Diagnosing: no easy task

Dr. Mendis stresses the importance of getting the diagnosis right. "Just because someone presents themselves with symptoms of depression does not mean that they have primary clinical depression," he says. Instead, depression could be the symptom of another, possibly more serious illness. Case in point, a large proportion of people with pancreatic cancer initially present with symptoms of depression and anxiety, he reveals.

"Depression might be drug induced, due to thyroid dysfunction or it might even be due to a brain tumour," he explains. "In the elderly, low salt levels are a common cause of depression. And usually when you rectify their salt levels their mood returns to normal." That it can be a potentially reversible condition only makes early and accurate diagnoses more essential.

Getting a proper history, including a family history, is important, after which depending upon a patient's profile, other investigations including brain imaging and blood testing might be required.

"Just because someone has a history of depression, it doesn't mean that each time they get depressed it's a recurrence of primary depression...it might be due to something else this time," cautions Dr. Mendis, adding that "people need to be treated early, because the consequences of misdiagnosis can be drastic”.

Treatment and recovery

Treatment for depression usually involves a combination of using medication and psychological therapies. The treatment package is custom designed, taking into consideration factors such as the intensity of symptoms, time frame of the episode and circumstances of the individual in question. In cases of severe depression, a combination of an antidepressant and cognitive behaviour therapy (CBT) may be advised by the doctor.

Also part of the arsenal of treatments is Electro Convulsive Therapy or ECT. "It is the most effective treatment for severe depression, to date," says Dr. Mendis, explaining that the process has been refined over the years and is now considered nothing short of a life saving procedure. "We use it a lot, for example in pregnancy, where medication can cause problems and when individuals do not respond to medication. It is also very effective in depression in the elderly, as well as in treating people who are suicidal or who are having great difficulty eating due to depression.”

Relapses are common in depression and the risk can only be lessened by adopting a holistic approach. Following your doctor's advice on your medication is crucial. "Relapses do occur, particularly if there is non-compliance with medication and if the environmental factors are not addressed...these are factors that perpetuate the condition, and if there is drug and alcohol abuse going in parallel with the treatment, it could lead to the rise of a chronic condition," he says. And the longer you suffer from a condition, the poorer your prognosis is.

Identification of the factors responsible for triggering the episode should be combined with concrete steps taken to rectify that situation, even if it means making difficult changes to your schedule. "If you broke your leg, you would know you need to rest it," he says. "If you are under too much strain at work, or you have ongoing family problems, or financial concerns, you need to address them." Seek medical advice as early as possible, and then stick to it, says Dr. Mendis. "A patient might stop medication early on, when they're feeling better, rather than continuing with it," he says, "which in turn increases relapse rates." For family and friends wanting to contribute, the best thing they can do is make sure that a patient is in a fairly relaxed environment and that he or she stays on medication as prescribed.