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TYPES OF DEPRESSION:
Major depression is manifested by a combination of symptoms (see symptom list) that interfere with the ability to work, study, sleep, eat, and enjoy once pleasurable activities. Such a disabling episode of depression may occur only once but more commonly occurs several times in a lifetime.
A less severe type of depression, dysthymia, involves long-term, chronic symptoms that do not disable, but keep one from functioning well or from feeling good. Many people with dysthymia also experience major depressive episodes at some time in their lives.
Another type of depression is bipolar disorder, also called manic-depressive illness. Not nearly as prevalent as other forms of depressive disorders, bipolar disorder is characterized by cycling mood changes: severe highs (mania) and lows (depression). Sometimes the mood switches are dramatic and rapid, but most often they are gradual. When in the depressed cycle, an individual can have any or all of the symptoms of a depressive disorder. When in the manic cycle, the individual may be overactive, overtalkative, and have a great deal of energy. Mania often affects thinking, judgment, and social behavior in ways that cause serious problems and embarrassment. For example, the individual in a manic phase may feel elated, full of grand schemes that might range from unwise business decisions to romantic sprees. Mania, left untreated, may worsen to a psychotic state.
SYMPTOMS OF DEPRESSION AND MANIA:
Not everyone who is depressed or manic experiences every symptom. Some people experience a few symptoms, some many. Severity of symptoms varies with individuals and also varies over time.
Depression:
* Persistent sad, anxious, or "empty" mood
* Feelings of hopelessness, pessimism
* Feelings of guilt, worthlessness, helplessness
* Loss of interest or pleasure in hobbies and activities that were once enjoyed, including sex
* Decreased energy, fatigue, being "slowed down"
* Difficulty concentrating, remembering, making decisions
* Insomnia, early-morning awakening, or oversleeping
* Appetite and/or weight loss or overeating and weight gain
* Thoughts of death or suicide; suicide attempts
* Restlessness, irritability
* Persistent physical symptoms that do not respond to treatment, such as headaches, digestive disorders, and chronic pain.
Mania:
* Abnormal or excessive elation
* Unusual irritability
* Decreased need for sleep
* Grandiose notions
* Increased talking
* Racing thoughts
* Increased sexual desire
* Markedly increased energy
* Poor judgment
* Inappropriate social behavior
Depression in Men:
Although men are less likely to suffer from depression than women, 3 to 4 million men in the United States are affected by the illness. Men are less likely to admit to depression, and doctors are less likely to suspect it. The rate of suicide in men is four times that of women, though more women attempt it. In fact, after age 70, the rate of men's suicide rises, reaching a peak after age 85.
Depression can also affect the physical health in men differently from women. A new study shows that, although depression is associated with an increased risk of coronary heart disease in both men and women, only men suffer a high death rate.
Men's depression is often masked by alcohol or drugs, or by the socially acceptable habit of working excessively long hours. Depression typically shows up in men not as feeling hopeless and helpless, but as being irritable, angry, and discouraged; hence, depression may be difficult to recognize as such in men. Even if a man realizes that he is depressed, he may be less willing than a woman to seek help. Encouragement and support from concerned family members can make a difference. In the workplace, employee assistance professionals or worksite mental health programs can be of assistance in helping men understand and accept depression as a real illness that needs treatment.
Major Depression info:
* Abnormal depressed mood:
o Sadness is usually a normal reaction to loss. However, in Major Depressive Disorder, sadness is abnormal because it:
+ Persists continuously for at least 2 weeks.
+ Causes marked functional impairment.
+ Causes disabling physical symptoms (e.g., disturbances in sleep, appetite, weight, energy, and psychomotor activity).
+ Causes disabling psychological symptoms (e.g., apathy, morbid preoccupation with worthlessness, suicidal ideation, or psychotic symptoms).
o The sadness in this disorder is often described as a depressed, hopeless, discouraged, "down in the dumps," "blah," or empty. This sadness may be denied at first. Many complain of bodily aches and pains, rather than admitting to their true feelings of sadness.
* Abnormal loss of interest and pleasure mood:
o The loss of interest and pleasure in this disorder is a reduced capacity to experience pleasure which in its most extreme form is called anhedonia.
o The resulting lack of motivation can be quite crippling.
* Abnormal irritable mood:
o This disorder may present primarily with irritable, rather than depressed or apathetic mood. This is not officially recognized yet for adults, but it is recognized for children and adolescents.
o Unfortunately, irritable depressed individuals often alienate their loved ones with their cranky mood and constant criticisms.
Major Depressive Disorder causes the following physical symptoms:
* Abnormal appetite:
o Most depressed patients experience loss of appetite and weight loss. The opposite, excessive eating and weight gain, occurs in a minority of depressed patients. Changes in weight can be significant.
* Abnormal sleep:
o Most depressed patients experience difficulty falling asleep, frequent awakenings during the night or very early morning awakening. The opposite, excessive sleeping, occurs in a minority of depressed patients.
* Fatigue or loss of energy:
o Profound fatigue and lack of energy usually is very prominent and disabling.
* Agitation or slowing:
o Psychomotor retardation (an actual physical slowing of speech, movement and thinking) or psychomotor agitation (observable pacing and physical restlessness) often are present in severe Major Depressive Disorder.
Major Depressive Disorder causes the following cognitive symptoms:
* Abnormal self-reproach or inappropriate guilt:
o This disorder usually causes a marked lowering of self-esteem and self-confidence with increased thoughts of pessimism, hopelessness, and helplessness. In the extreme, the person may feel excessively and unreasonably guilty.
o The "negative thinking" caused by depression can become extremely dangerous as it can eventually lead to extremely self-defeating or suicidal behavior.
* Abnormal poor concentration or indecisiveness:
o Poor concentration is often an early symptom of this disorder. The depressed person quickly becomes mentally fatigued when asked to read, study, or solve complicated problems.
o Marked forgetfulness often accompanies this disorder. As it worsens, this memory loss can be easily mistaken for early senility (dementia).
* Abnormal morbid thoughts of death (not just fear of dying) or suicide:
o The symptom most highly correlated with suicidal behavior in depression is hopelessness.
Associated Features and Comorbidity
* Anxiety:
o 80 to 90% of individuals with Major Depressive Disorder also have anxiety symptoms (e.g., anxiety, obsessive preoccupations, panic attacks, phobias, and excessive health concerns).
o Separation anxiety may be prominent in children.
o About one third of individuals with Major Depressive Disorder also have a full-blown anxiety disorder (usually either Panic Disorder, Obsessive-Compulsive Disorder, or Social Phobia).
o Anxiety in a person with major depression leads to a poorer response to treatment, poorer social and work function, greater likelihood of chronicity and an increased risk of suicidal behavior.
* Eating Disorders:
o Individuals with Anorexia Nervosa and Bulimia Nervosa often develop Major Depressive Disorder.
* Psychosis:
o Mood congruent delusions or hallucinations may accompany severe Major Depressive Disorder.
* Substance Abuse:
o The combination of Major Depressive Disorder and substance abuse is common (especially Alcohol and Cocaine).
o Alcohol or street drugs are often mistakenly used as a remedy for depression. However, this abuse of alcohol or street drugs actually worsens Major Depressive Disorder.
o Depression may also be a consequence of drug or alcohol withdrawal and is commonly seen after cocaine and amphetamine use.
* Medical Illness:
o 25% of individuals with severe, chronic medical illness (e.g., diabetes, myocardial infarction, carcinomas, stroke) develop depression.
o About 5% of individuals initially diagnosed as having Major Depressive Disorder subsequently are found to have another medical illness which was the cause of their depression.
o Medical conditions often causing depression are:
+ Endocrine disorders: hypothyroidism, hyperparathyroidism, Cushing's disease, and diabetes mellitus.
+ Neurological disorders: multiple sclerosis, Parkinson's disease, migraine, various forms of epilepsy, encephalitis, brain tumors.
+ Medications: many medications can cause depression, especially antihypertensive agents such as calcium channel blockers, beta blockers, analgesics and some anti-migraine medications.
Mortality:
Up to 15% of patients with severe Major Depressive Disorder die by suicide. Over age 55, there is a fourfold increase in death rate.
Premorbid History.
10-25% of patients with Major Depressive Disorder have preexisting Dysthymic Disorder. These "double depressions" (i.e., Dysthymia + Major Depressive Disorder) have a poorer prognosis.
Gender.
Males and females are equally affected by Major Depressive Disorder prior to puberty. After puberty, this disorder is twice as common in females as in males. The highest rates for this disorder are in the 25- to 44-year-old age group.
Prevalence.
The lifetime risk for Major Depressive Disorder is 10% to 25% for women and from 5% to 12% for men. At any point in time, 5% to 9% of women and 2% to 3% of men suffer from this disorder. Prevalence is unrelated to ethnicity, education, income, or marital status.
Onset And Course.
* Onset:
o Average age at onset is 25, but this disorder may begin at any age.
* Psychological stress:
o Stress appears to play a prominent role in triggering the first 1-2 episodes of this disorder, but not in subsequent episodes.
* Duration:
o An average episode lasts about 9 months.
* Course:
o Course is variable. Some people have isolated episodes that are separated by many years, whereas others have clusters of episodes, and still others have increasingly frequent episodes as they grow older.
o About 20% of individuals with this disorder have a chronic course.
Recurrence
* The risk of recurrence is about 70% at 5 year follow up and at least 80% at 8 year follow-up.
* After the first episode of Major Depressive Disorder, there is a 50%-60% chance of having a second episode, and a 5-10% chance of having a Manic Episode (i.e., developing Bipolar I Disorder). After the second episode, there is a 70% chance of having a third. After the third episode, there a 90% chance of having a fourth.
* The greater number of previous episodes is an important risk factor for recurrence.
Suicide risk:
* · For people diagnosed with major depression, the lifetime risk of suicide may be as high as 6% [3], although this figure may be more applicable to those who have been admitted to hospital as a result of depression. For people seen as outpatients or treated by GPs, risks are much lower .
* For those with bipolar disorder the suicide risk is much higher, at 15 times that of the general population. This risk is further increased by a previous suicide attempt and by alcohol abuse.
# Important psychiatric risk factors for suicide amongst people with any form of depression include:
* Previous self-harm.
* Severity of the illness.
* Alcohol or drugs abuse.
* Serious or chronic physical illnesses.
* Schizophrenia.
# Important amongst demographic and social factors included are:
> * Being male.
> * Middle age.
> * Social isolation.
# Research shows that depression is one of the most frequent mental health problems in people who die by suicide. This is also true of young people; major depression is common amongst adolescents who have overdosed.
# Other factors may be important, either independently or in combination with depression, in the development of suicidal thoughts and behaviour in an individual. Such factors include impulsiveness, aggressiveness, addiction, suicide or suicide attempts in close relatives, divorce, separation and parental discord.
# Depression is common amongst people who self-harm, both in those who habitually self-harm by for example, self-cutting, without suicidal intent and in those who may have suicidal intent when they self-harm .
# In people who have self-harmed, depression and impulsivity have been shown to be strongly associated with the strength of the intent to die by suicide.
# Major, or severe, depression in adolescence is associated with higher risk of both suicide attempting and death by suicide in adulthood.
# Although dysthymia in itself is not related to suicide, 10% of those suffering from it will go on to develop major depression.
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