Depression Doctors often come across such patients who present themselves with symptoms which apparently have no physical basis. Careful and detailed assessment and investigation reveals no abnormality. This is frustrating for the physician but more so for the patient and his family. They assume that the doctor did not understand the problem, and turn to hakims, spiritual healers and shrines which does not solve the problem either. Symptoms of depression Depression is usually accompanied by physical symptoms called somatic symptoms i.e. headache, abdominal disturbance, constipation, bodyache, dizziness, palpitation and lack of appetite and sleep. In the initial phase the patient usually complains of bodily symptoms to the doctor who tries to remove them by symptomatic treatment, but without success. Only on enquiring do most patients admit that they have depressed feelings. According to a research study we conducted, 90 out of 100 patients with depression presented with either dizziness, headache and/or palpitation, but on further enquiry, they admitted to the typical features of depression as well i.e. sadness, hopelessness, helplessness, weeping, low appetite, insomnia, death wishes or suicidal thoughts etc. The patient has no energy to do anything. There is a lack of interest in routine activities, he becomes irritable, all things seem dull, and life looks colourless and dark. Patients attempt suicide and the majority of suicides reported are due to this illness. Misnomers When doctors can’t find any physical basis for the symptoms they many pick on some symptoms like “low blood pressure” for explanation. Another scape goat is “abdominal gas”. Types of depression Depression can be divided into mild, moderate or severe according to its severity. Moreover the diagnosis should mention whether there are accompanying somatic or psychotic symptoms. Patients with severe depression sometimes present themselves with delusions and hallucinations. These patients have paranoid ideas and think that people are against them. Some patients may hear voices which have no existence and sometimes patients feel foul smells. etc. This is called Psychotic Depression. For this condition in addition to antidepressants and anti-psychotics, ECT should also be given. Etiology Latest research shows that depression is caused by a change in neurotransmitter level within the brain. Noradrenaline and serotonin are the main neurotransmitters whose deficiency is the underlying cause of depression but it can be precipitated and/or worsened by severe stress, psychological or social. Often patients suffer from depression without facing stress which indicates that depression is not always caused by stress or adverse life-events, but is due only to chemical changes in the brain. Another contributing factor is genetics. This illness runs in the family. Many organic conditions and chronic physical illnesses can also cause depression. Moreover some medicines, e.g. anti-hypertensives, can also cause depression as a side effect. Treatment 1. Physical a) Medicines b) ECT 2. Psychological treatment a) Cognitive therapy b) Psychotherapy 3. Social treatment a) Social support 1. (a) Medicines (see attached medicine list) If patient suffers from insomnia start treatment of depression with the Tricyclics specially Sensival, Amyline or Imidol as they are effective and cheap. If severe side effects develop shift to Mirtazep as this is also sedative. If sleep is normal or increased, then use the SSRIS. The SSRIS are all equally effective so start with the cheapest one Fluoxitine (Rize or Zauxit). If this is not tolerated or 3-4 weeks of therapy do not lead to enough improvement then shift to the following in the order given: 1. Citalopram (Manipram / Citalo) 2. Serteraline (Seroft / Reline) 3. Paroxitine (Peroxit / Paroxyl) 4. Escitalopram (Citanew, esilopram) If sleeping at night is difficult then hypnotics like Lorazepam (Tenzil, emotivan, Ativan) or Noctamid may be given. If there is day time drowsiness with these hypnotics use the ultra short duration hypnotic zolpidem (Siesta, Zolp). Please note that the minimum and maximum dose of all the above drugs are given
in the chart of Anti depressants, along with the side effects and other characteristics. HORMONE REPLACEMENT At the age of 40 or above women should be specifically asked about excessive sweating and the body feeling hot at times, specially the face, hands and soles of the feet. Those are symptoms of ovarian hormone deficiency, which should then be given to the patient. The quantities of estrogen and progesterone present in contraceptive tablets. (Famila etc) are sufficient. If the patient is menstruating she should be started hormone tablets on the fifth day of her menstruation and then given a tablet daily for 21 days. Then none for 7 days and restarted again till 21 days have passed followed by an interval of 7 days. If menopause has occurred then the hormone tablet should be given continuously, without any break, so as to avoid vaginal bleeding. In a women with hysterectomy only estrogen should be given and not progesterone. These hormones are usually needed for 6-12 months 1. (b) ECT ECT is indicated if depression is severe, there are psychotic symptoms, the patient is suicidal, very withdrawn and/or not eating or drinking adequately. ECT is very effective and does not have any serious side effects. For maximum effect ten ECT treatments should be given, usually twice a week. ECT without anaesthesia is preferable as it is cheap and has less side effects. However to avoid the risk of fracture or due to personal preference it may be given under anaesthesia. Clinical case of depression 1. Perveen Perveen mentioned that she has no interest in going out, has lack of confidence, and inferiority complex. She was very much concerned about her face complexion. When she was studying in school other girls seemed fairer and from richer families. She got depressed, became isolated, having no interest in anything. She also complains of hearing a whistling sound in her ears, has death wishes and feels weak. Perveen is 22 years old and is suffering from depression since 1 year. Her mother was quite upset due to her condition, because she was irritable and showing outburst of anger at minor things. Her mother mentioned that due to profuse vaginal discharge she was avoiding going out. So much so that she did not participate in her brother’s wedding, which took place recently. She was prescribed antidepressants. In the beginning she did not respond well. One day she took an over dose to kill herself. She was admitted in the hospital, where antidepressants and ECT was given. 2. Nasiban Nasiban is a 40 years old married woman with 3 sons and 4 daughters. One son is married. She lives with son and his wife. Her husband has a scrap business. She complained that she has anger outbursts, insomnia, frightening dreams, headache, loss of appetite, excessive sweating, hot flushes, sadness, weeping spells, death wishes, suicidal thoughts, and paranoid ideas about relatives. Diagnosis 1) Depression - moderate 2) Post Menopausal Hormonal Deficiency Treatment In addition to Antidepressants and ECT she was also given estrogen and progesterone replacement tablets (Famila). |
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