Depression causes a continuous feeling of sadness and may occur post-pregnancy as postpartum depression. Understanding depression symptoms can help treatment.

Depression

PNS SHIFA

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Syed Intisar Hussain

Overview

Depression is a common, but serious, mood disorder that triggers feelings of sadness and loss of interest in daily activities, such as sleeping, eating, and working.

Depression or clinical depression is a major mood disorder that affects the way you think, feel and cope with emotional and physical problems. Depression is more than just about feeling the blues, it affects your usual day-to-day activities and may even make you feel like life is not worth living. It&rsquo;s not something you can simply snap out of and may require long-term treatment. Most people tend to feel better with medication, psychotherapy, or both.&nbsp;

 
More than 20 million Pakistanis, which makes up 10% of the population, are plagued with mental health issues. Despite the recent surge of mental health concerns in the population, the country falls under the lowest psychiatrist-to-person ratio in the world. The World Health Organization further highlights that there are only 400 psychiatrists and five psychiatric hospitals in a country with a population of more than 180 million people<a href="#accordion">[1]</a>.&nbsp;

A lack of awareness about mental health issues and the stigma around mental health is one of the main reasons South Asian countries are plagued with mental health issues. To date, mental health issues are largely dismissed; the symptoms of mental illnesses are attributed to possession by demons, the evil eye, and black magic, which is a hindrance when it comes to getting professional help. Other common reasons for mental health issues, such as depression in Pakistan include poverty, homelessness, displacement, and unemployment. Depression is a major public health concern. However, despite that, the true prevalence of mental health issues in Pakistan is unknown because of a lack of research and stigmatisation&nbsp;of mental health issues.&nbsp;

 
Though depression can happen at any age, it often begins during adulthood. It is now recognized as a common problem in both children and adults. Similarly, in some cases, it may also co-occur with other serious medical illnesses, for example, Parkinson&rsquo;s disease, heart disease, cancer, and diabetes. Certain medications may also cause depression. A doctor experienced with mental health issues will be able to work out the best treatment strategy for you.

&nbsp;

Depression causes severe symptoms that may affect the way you feel, think, or cope with life and stressful situations in general. However, some forms of depression may develop under unique circumstances.&nbsp; 
&nbsp;

<ul>
	<li>
	<h5>Persistent Depressive Disorder&nbsp;</h5>
	</li>
</ul>

Persistent depressive disorder, also known as dysthymia, is described as a depressed mood that lasts for more than 2 years. People diagnosed with persistent depressive disorders often present with episodes of both symptoms of major depression and less severe symptoms. However, for a definitive diagnosis, the symptoms must last for 2 years. 
&nbsp;

<ul>
	<li>
	<h5><a href="https://merisehat.pk/disease/postpartum-depression">Postpartum Depression&nbsp;</a></h5>
	</li>
</ul>

Postpartum depression is characterized by mild to severe symptoms of depression and anxiety that generally clear 2 weeks after giving birth. However, postpartum depression is more than just &ldquo;baby blues&rdquo; and can affect parents of any age, race, culture, income, or educational level.&nbsp;

Women with postpartum depression often experience the symptoms of depression during pregnancy and after delivery. The exhaustion of childbirth accompanied by depression may make it completely impossible for new mothers to go about their day-to-day tasks and take care of their babies. 
&nbsp;

<ul>
	<li>
	<h5>Psychotic Depression&nbsp;</h5>
	</li>
</ul>

Psychotic depression is an amalgamation of severe depression and a form of psychosis, for example, hearing or seeing upsetting things that aren&rsquo;t real (hallucinations) and false fixed beliefs or delusions. The psychotic symptoms generally revolve around illness, guilt, and poverty.&nbsp; 
&nbsp;

<ul>
	<li>
	<h5>Seasonal Affective Disorder&nbsp;</h5>
	</li>
</ul>

Seasonal affective disorder, also known as SAD, is described as the onset of depression during the winter months. This type of depression begins at the same time every year, sapping your energy and making you feel sad. However, the symptoms usually resolve during spring and summer. The decrease in sunlight during the winter months disrupts the circadian rhythm or the body&rsquo;s internal clock and causes depression. Reduced sunlight can also cause a drop in serotonin, dubbed the &ldquo;feel-good&rdquo; hormone levels, and trigger depression. In addition, it also disrupts the body&rsquo;s levels of melatonin which affects mood and sleep patterns. Symptoms of SAD generally include increased sleep, social withdrawal, and weight gain. 
&nbsp;

<ul>
	<li>
	<h5><a href="https://merisehat.pk/disease/bipolar-disorder">Bipolar Disorder</a>&nbsp;</h5>
	</li>
</ul>

Bipolar disorder is not a form of depression but often triggers episodes of extremely low moods which meet the criteria of major depression. However, a person with bipolar disorder may also experience euphoric or irritable moods called &ldquo;mania&rdquo; or &ldquo;hypomania&rdquo;. 
&nbsp;

Signs And Symptoms

Not everyone who is depressed experiences the same symptoms. While others may experience severe symptoms, some people may only experience milder ones. The severity and frequency of symptoms vary, depending on the stage of the illness. The symptoms of depression may include:&nbsp;

<ul>
	<li>Persistent feelings of sadness or impending doom&nbsp;</li>
	<li>Feeling of hopelessness&nbsp;</li>
	<li>Irritable mood&nbsp;</li>
	<li>Feeling guilty, worthless, and helpless&nbsp;</li>
	<li>Loss of interest in activities that you once enjoyed doing&nbsp;</li>
	<li>Fatigue or decreased energy&nbsp;</li>
	<li>Moving and talking slowly&nbsp;</li>
	<li>Restlessness and trouble sitting still</li>
	<li>Difficulty concentrating and making decisions, or memory problems</li>
	<li><a href="https://merisehat.pk/disease/sleep-apnea-91">Difficulty sleeping</a>, oversleeping, or waking up early&nbsp;</li>
	<li>Loss of appetite&nbsp;</li>
	<li>Unexplained weight changes&nbsp;</li>
	<li>Thoughts of suicide&nbsp;</li>
	<li>Body aches, headaches, digestive problems without an underlying cause that don&rsquo;t improve with treatment, and cramps</li>
</ul>

If you experience any of these symptoms nearly every day and have been experiencing them for at least two weeks, seek professional help immediately.

&nbsp;

Causes

The causes of depression are not fully understood. Researchers believe that several possible causes combined with various other factors may trigger depression. Factors that may trigger depression include:&nbsp;

<ul>
	<li>Physical, sexual, or emotional abuse&nbsp;</li>
	<li>Living alone or having a lack of social support&nbsp;</li>
	<li>Elderly people are at a higher risk of developing depression&nbsp;</li>
	<li>Certain medications such as isotretinoin, used for the treatment of acne, antiviral drug interferon-alpha, and corticosteroids&nbsp;</li>
	<li>Personal conflicts and disputes with family or friends</li>
	<li>Death of a loved one&nbsp;</li>
	<li>Hormonal changes in women, such as in the case of pregnancy&nbsp;</li>
	<li>A family history of depression&nbsp;</li>
	<li>Genetic diseases Huntington&#39;s chorea or <a href="https://merisehat.pk/disease/cystic-fibrosis">cystic fibrosis</a></li>
	<li>Major events such as losing a job, retiring, getting divorced, and even good events, such as starting a new job, getting married, or graduating can lead to depression.</li>
	<li>Social isolation&nbsp;</li>
	<li>Medical illnesses such as <a href="https://https://merisehat.pk/disease/diabetes-type-1-and-2">diabetes</a>, heart disease, kidney disease, HIV, <a href="https://merisehat.pk/disease/arthritis">arthritis</a>, lupus, multiple sclerosis, chronic pain, and <a href="https://merisehat.pk/disease/hypothyroidism">hypothyroidism</a>.&nbsp;</li>
	<li>Substance misuse, such as drugs or alcohol</li>
</ul>

&nbsp;

Diagnosis

The Patient Health Questionnaire (PHQ)-2 and PHQ-9 are the commonly used and validated screening tools for depression. The questionnaire inquires about the degree to which the individual has experienced a depressed mood for the past two weeks. The purpose of the test is to only screen for depression and not establish a final diagnosis or monitor for depression. In addition, the &quot;Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition&quot; (DSM-5) is used for the diagnosis of a multitude of mental health disorders. Including depressive disorders, trauma- and stressor-related disorders, personality disorders, and eating disorders.

&nbsp;

&nbsp;

<h4>Depression DSM-5 Dagnostic Criteria&nbsp;</h4>

DSM-5 is a manual for the assessment and diagnosis of mental health disorders. However, it does not include any guidelines for treatment.&nbsp;

The DSM-5 outlines the following criteria to make the diagnosis of depression. !t least 5 of the following symptoms have to be present for at least 2 weeks for the diagnosis of depression:&nbsp;

<ul>
	<li>Depressed mood most of the day or nearly every day. In children and adolescents, it can also be an irritable mood.&nbsp;</li>
	<li>Loss of interest in almost all activities most of the time or nearly every day.&nbsp;</li>
	<li>Unexplained weight loss or change in appetite. For children, it can present as a failure to achieve the expected weight gain.&nbsp;</li>
	<li>Sleep disturbance, trouble falling or staying asleep (insomnia), or excessive sleeping during the day even after a good night&rsquo;s sleep (hypersomnia).&nbsp;&nbsp;</li>
	<li>Psychomotor retardation, slowing down of thought, or reduction of physical movement observable by others.</li>
	<li>Fatigue or loss of energy.</li>
	<li>Feelings of worthlessness or feeling of guilt nearly every day.&nbsp;</li>
	<li>Indecisiveness or inability to think or concentrate.&nbsp;</li>
	<li>Recurrent thoughts of death and suicidal ideation without a specific plan or a specific plan to commit suicide or attempt suicide.&nbsp; 
	&nbsp;</li>
</ul>

The symptoms of depression can be mild, moderate, or severe, and cause significant distress in social or occupational settings and other important areas of functioning. DSM-5 helps distinguish between normal sadness and a major depressive disorder.&nbsp;

&nbsp;

If you are suffering from any of the above symptoms, then you should seek professional help immediately. Depression is diagnosed based on the presenting symptoms and how long the symptoms have been present. The doctor may also order blood tests to rule out any underlying health conditions.&nbsp;

&nbsp;

A mental health professional will also ask you to fill out a questionnaire to assess the severity of depression. The tests include:

<ul>
	<li>The Hamilton Depression Rating Scale: This scale classifies the symptoms of depression as&nbsp;0 - absent; 1 - mild; 2 - moderate; 3 - severe; 4 - incapacitating. The higher the score, the more severe the depression experienced.</li>
	<li>The Beck Depression Inventory: This test measures the characteristic attitudes and symptoms of depression. The test has 21 multiple-choice questions and respondents are asked to rate each item based on four response choices according to how severe the symptoms are. The symptoms range from absent to severe.&nbsp;</li>
</ul>

&nbsp;

<h4>Mental health disorders can lower your heart rate variability. Head on over to the <a href="https://www.merisehat.pk/page/sehat-scan/" target="_blank">sehat scan</a> and get your reading today!</h4>

Treatment

While there is no cure for depression, there is a combination of treatments that may help with managing the symptoms and recovery. Many people with depression recover with the following management plan. However, even with treatment, relapses may occur.&nbsp; 
&nbsp;

<h5>Medication&nbsp;</h5>

<ul>
	<li>Selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs)</li>
	<li>Tricyclic and tetracyclic antidepressants</li>
	<li>Noradrenaline and dopamine reuptake inhibitors (NDRIs)</li>
	<li>Monoamine oxidase inhibitors (MAOIs)</li>
	<li>N-methyl D-aspartate (NMDA) antagonists&nbsp;</li>
</ul>

&nbsp;

The medications should only be taken when prescribed by a doctor. Some drugs may take a while to show improvements, though, by stopping a drug you may not experience the complete benefits. In addition, some people stop taking medications once they start seeing improvements, but this can lead to relapses.

&nbsp;

<h5 dir="ltr">Other Approaches</h5>

Other treatment approaches for depression include:

<ul>
	<li>Counselling Or Psychotherapy &ndash; Speaking with a therapist can help you cope with negative feelings. Psychotherapy is often used alongside drug treatment and has shown to be an effective approach to the treatment of depression.&nbsp;</li>
	<li>Cognitive Behavioural Therapy (CBT) &ndash; In CBT, the therapist will work with you and help you uncover unhealthy patterns of thought, attitudes, and beliefs. The therapist will further help you identify harmful behaviors, reactions, and beliefs, in addition to helping you replace your negative thoughts with more positive thoughts.&nbsp;</li>
	<li>Dialectical Behavior Therapy (DBT) &ndash; DBT specifically emphasizes accepting uncomfortable thoughts and feelings to make a recovery plan.&nbsp;</li>
	<li>Psychodynamic Therapy &ndash; In this approach, the therapist will help you better understand and cope with your day-to-day life.&nbsp;</li>
	<li>Light Therapy &ndash; Light therapy is a common treatment approach for SAD, where patients are exposed to white light to help regulate their mood and improve symptoms of depression.&nbsp;</li>
	<li>Electroconvulsive Therapy (ECT) &ndash; ECT is designed to use electric currents to induce seizures. While ECT has been shown to help people with severe clinical depression, it has several side effects such as headaches, muscle aches, nausea, soreness, confusion, and disorientation, and is not routinely used.</li>
	<li>Alternative Therapies - This includes meditation and acupuncture.&nbsp; 
	&nbsp;</li>
</ul>

Depression is a serious disorder that often gets worse if not treated. This can cause emotional, behavioral, and health problems. The complications of depression include:&nbsp;

<ul>
	<li>Excess weight gain or obesity may lead to diabetes and heart diseases&nbsp;</li>
	<li>Pain and physical illness&nbsp;</li>
	<li><a href="https://merisehat.pk/disease/dangers-of-cannabis-abuse">Drug misuse</a>&nbsp;</li>
	<li>Panic disorder, anxiety, and social phobia&nbsp;</li>
	<li>Relationship problems&nbsp;</li>
	<li>Family problems&nbsp;</li>
	<li>Difficulty with work and school&nbsp;</li>
	<li>Social isolation&nbsp;</li>
	<li>Feelings of suicide&nbsp;</li>
	<li>Self-harm</li>
	<li>Premature death because of medical conditions</li>
</ul>

&nbsp;

Depression can occur at any age. However, it is more commonly diagnosed in women than in men. Factors that may trigger depression include:&nbsp;

<ul>
	<li>Personality traits such as being too self-critical or pessimistic, dependent, and having low self-esteem.&nbsp;</li>
	<li>Family history of suicide, alcoholism, bipolar disorder, and depression.&nbsp;</li>
	<li>Being transgender or having variations in the development of genital organs or being intersex.&nbsp;</li>
	<li>History of other mental health problems, for example, post-traumatic stress disorder, eating disorders, and anxiety disorders.&nbsp;</li>
	<li>Misuse of drugs&nbsp;</li>
	<li>Chronic illnesses, such as heart disease, chronic pain, and cancer.&nbsp;</li>
	<li>Certain medications, for example, sleeping pills and medications used for the treatment of high blood pressure. 
	&nbsp;</li>
</ul>

There is no guaranteed way to prevent depression. However, there are a few strategies that may be helpful:&nbsp;

<ul>
	<li>Control Stress. Take steps to control stress, boost your self-esteem, and increase resilience.&nbsp;</li>
	<li>Reach out to family and friends for support, especially in times of crisis.&nbsp;</li>
	<li>Seek professional help at the earliest signs of the problem to prevent it from worsening.&nbsp;</li>
	<li>Consider long-term maintenance treatment, such as therapy to prevent the relapse of symptoms. 
	&nbsp;</li>
</ul>

Key Points

<ul>
	<li>Depression or clinical depression is a common mood disorder that triggers feelings of sadness and affects the way you think, feel, and cope with life in general.&nbsp;</li>
	<li>More than 20 million Pakistanis, which make up 10% of the population, are plagued with mental health issues.</li>
	<li>Though depression can happen at any age, it often begins during adulthood. It is now recognized as a common problem in both children and adults.</li>
	<li>There is currently no cure for depression. Though, there are a combination of treatments that may help with managing the symptoms, and recovery.</li>
</ul>

&nbsp;

[1] Nisar, M., Mohammad, R.M., Fatima, S., Shaikh, P.R. and Rehman, M., 2019. Perceptions pertaining to clinical depression in Karachi, Pakistan. Cureus, 11(7).