Depression (Major Depression)
We all experience ups and downs in life and can normally get through periods when our mood is lower than usual. When symptoms of low mood are more persistent and go on for more than two weeks and affect the way that the person functions, either in their work or in their home life it is likely that they are suffering from Major Depression.
Sometimes people don't seek treatment for their depressive symptoms and the condition can get worse. The good thing about Major Depression is that it is very treatable. In the mild and moderate stages of depression the condition can be treated by psychological treatment. When things become more severe is often necessary to prescribe antidepressant medication. Is important to remember that most people who experience Major Depression get better.
With Major Depression the person experiences sad, anxious or empty feelings. For some people the anxiety symptoms are more distressing and disabling than the mood symptoms. The person may feel hopeless and have lost interest in things they normally enjoy. They might feel guilty for things that are not really their fault or responsibility.
The person may experience increased fatigue and reduced energy levels. There might be problems with concentrating, for example reading or following the story on a television show. The person may experience insomnia and sometimes there can be excessive sleeping during the daytime. Early-morning wakening is a classic feature of a Major Depressive disorder with person waking at 3 or 4 am a then being unable to get back to sleep.
Sometimes people suffering with Major Depression can experience physical symptoms such as back pain, headaches or problems with their bowels. If the person's appetite it affected it is reduced usually, but sometimes people may over eat. The person may experience suicidal thoughts. They may just be fleeting thoughts but sometimes the thoughts can be more severe and can potentially lead to a suicide attempt. This is one reason why Major Depression needs to be taken seriously. The World Health Organisation states that major depression is the leading cause of disability worldwide. Apart from the cost to the sufferer and their families the economic costs to society in general are huge. This is why optimising treatment in a timely way is so important.
I am now really excited to be able to offer patients the option of having a genetic test which can help optimise medication treatment decisions. The test identifies genetic markers, which can indicate the treatments that are likely to work and those that are more likely to lead to side effects. The test involves taking a cheek swab and then sending the sample to a laboratory in the U.S.A. for analysis. The testing I hope will be helpful in treating patients who have failed to respond to their first or second antidepressant or have had significant side effects.
Some people who experience a Major Depressive Episode and recover might never experience another episode again. However there are some people that will have more than one episode and this is called Recurrent Depressive Disorder. The episodes need to have been separated by several months of normal mood for this condition to be diagnosed. By successful treatment the risk of further relapses can be reduced.
When a Major Depressive Episode becomes very severe the person might start to experience psychological symptoms they have never had before. These might be worrying thoughts about other people trying to harm them, for example. The thoughts may be a little bit more excessive than normal but sometimes the thoughts develop to point where the person might lose touch with outside reality. This type of thought is called a delusion. Sometimes someone with psychotic depression may see or hear something that isn't there. These symptoms are called visual and auditory hallucinations. Thankfully these symptoms respond well to treatment medication and may never come back again with appropriate treatment.
It is not uncommon for a woman, after having a baby, to have a downturn in her mood. This period, lasting couple of days, is usually called the "baby blues" period. When the downturn in mood is more prolonged and more severe it is called postpartum depression. Post-partum depression occurs in approximately 10% of women after giving birth. Is important that the condition is diagnosed and treated early on for the well being of both mother and the baby. If the condition is not treated properly it can lead to problems with bonding and attachment. Sometimes postpartum depression can be so severe that the mother experiences psychotic symptoms. In these circumstances intensive treatment is required.
This is the name given to a more severe form of the premenstrual syndrome. It is associated with the hormonal changes occurring around the time of ovulation before the menstrual period begins. It is a relatively common condition affecting between 3% and 8% of women of reproductive age. Relative changes in oestrogen and other female hormones have an effect on the neurotransmitters involved in depression. There is likely to be a genetic reason why some women develop this condition and others do not. There is clear evidence that this condition can be successfully treated with hormonal treatment, cognitive behaviour therapy and antidepressant treatment. Quite of the condition goes undiagnosed and is undertreated.
For some people their Major Depressive Episodes seem to come on in the winter months. There is an association between the onset of their mood symptoms and the reduction in the amount of sunlight there is. Often their depressive symptoms lift when spring comes. Often the condition starts and ends at the same times each year. It has taken some time for SAD to be fully recognised as a real medical condition, but now it is fully recognised as such. The condition can be treated with light therapy (phototherapy), psychological treatment and antidepressant medication.
As with all mental health problems, taking a detailed history is very important. When taking a history particular attention is paid to the social and psychological background of the person as well as their physical health and how that might be affecting their mood. Checking medication that the person is taking is also an important aspect of the assessment as some medicines can cause depression. If a person has suffered with the condition in the past is useful to have very clear picture of the types of treatment that they have had in the past so that one is at having worked on tried again.
There are a wide variety of medical conditions, which can present with symptoms of depression and these conditions need to be excluded before making the diagnosis. Some of the neurological conditions, which can mimic a depressive disorder, are described in the neuropsychiatric section on the memory page on this site. Hormonal problems such as too much or too little thyroid hormone can cause depression. Sometimes infections, such as glandular fever, can mimic depression. Problems with sleeping, including specific sleep disorders, can lead to someone developing symptoms of depression. Prescription medicines and drugs of abuse can also cause depression.
Depression commonly occurs with the anxiety disorders listed on the anxiety page.
When I am taking a history it is important for me to establish whether a person has had periods in their life when they have experienced episodes of elevated mood. These periods may have been relatively mild and not severe enough to come to the attention of a doctor. They may indicate that the person could be on the bipolar spectrum. At one time it was thought that probably only about 5%-10% of patients who suffer with depression had a tendency to bipolar disorder. In recent times the consensus seems to be that as many as 50% of people with depressive disorder could be on the bipolar spectrum many of whom would not meet the full diagnostic criteria for bipolar disorder. This is important because if a psychiatrist suspects that person they are treating the depression could be on the bipolar spectrum that care is taken to watch for any symptoms elevated mood. Taking a detailed history from friends and family can be helpful in establishing if there have episodes of elevated mood.
Blood tests and other physical investigations such as EEG and brain scans may be required in a small number of patients to establish if there is a physical cause for the depression they are experiencing.
Cognitive Behavioural Therapy
The aim of CBT is to develop more helpful thoughts and actions that can guide us towards happier and more fulfilling lives. With this short-term therapy the therapist works actively and collaboratively with the patient. With the help of the therapist the patient discovers unhelpful learned patterns of thoughts and behaviours. For most patients treatment lasts about three months. The patient sees the therapist on a weekly basis usually and the sessions last about 50 minutes.
The patient keeps records of their thoughts, emotions behaviours. Challenging the automatic negative thoughts that appear in the consciousness of someone who is depressed is a key part of the treatment strategy. In time the person learns to gain mastery over their behaviour, thoughts and emotions.
This form of treatment is useful in treating mild and moderate depressive disorder. In people with more severe depressive illnesses I would usually recommend antidepressant medication. People with severe depression, when they respond to medication, are then usually amenable to this form of psychological treatment. I refer to a wide network of therapists and always do my best to try and match the patient under my care to the right therapist. If for whatever reason there is a problem with that match we can always discuss this and arrange for an alternative therapist to take over.
Most antidepressants work by boosting levels of two key important neurotransmitters in the brain called serotonin and noradrenaline. Some drugs work by blocking the enzyme that recycles these neurotransmitters and other drugs work by directly acting on receptors to which these neurotransmitters bind. The drugs start working from day one. In the first few days there is often a surge of the neurotransmitters, which can lead to symptoms such as nausea and increased anxiety. I always advise patients at this might happen and sometimes will prescribe a benzodiazepine drug short-term to help reduce the anxiety.
Research has shown that patients suffering with depression who start taking antidepressants start to perceive things in a less negative way after about the first week. It is usually at least a week later before the person starts to notice an improvement in their mood. Sometimes it can take several weeks to see a mood improvement response. The response to treatment does tend to take longer older patients.
Like all medicines there is a significant placebo effect with standard antidepressants. This is roughly at the level of about 40%. It is probably so high because research studies tend to recruit patients with a mild/ moderate degree of severity and less patients at the more severe end of the spectrum that we sometimes see in our specialist clinics.
When a Major Depressive Disorder has gone on for over two years the person is said to have a Persistent Depressive Disorder. Sometimes this might be because the treatment that has been offered has been ineffective. Is important not to give up on the patient and to keep trying new ways to help them get better.
Quite often a combination of medication treatments are required to get the person completely better. Sometimes high doses of antidepressants are used. Lithium carbonate is sometimes added to an antidepressant when it has failed to work. Antipsychotic medication may help particularly drugs that block specific serotonin (5-HT 2A) receptors. Combining drugs in order to treat treatment resistant depression is a complex business and needs to be done by a specialist. A great deal of care is taken in the planning of this type of treatment to reduce the risk that patients may develop side effects.
Electroconvulsive therapy (ECT)
Electroconvulsive therapy can help patients who have severe depression, which is not responding to medication. This treatment can be life saving. It has save some of my most severely ill patients their lives. A small amount of electrical charge is applied to the patient's head whilst they are anaesthetised. A seizure then occurs which leads to changes in blood flow and metabolism in the brain. There is a large release of neurotransmitters, which is probably how it works. The use of ECT remains controversial and there widely differing views on its use despite it being generally regarded in psychiatry as a safe and effective treatment. Treatment is usually given when the patient is an in-patient. For safety reasons this treatment is done at NHS facilities although the patient can be resident in a private clinic.
Transcranial magnetic stimulation (TMS)
Transcranial magnetic stimulation (TMS) is a procedure that uses magnetic fields to stimulate nerve cells in the brain to improve symptoms of depression. Transcranial magnetic stimulation may be tried when other depression treatments have been unsuccessful. This treatment option, all ready popular in the United States, is being to be tried more in the UK. I have links to private facilities in London.
During treatment a large electromagnetic coil is placed against the person's scalp close to the forehead. The electromagnet creates electric currents that stimulate nerve cells in regions of the brain involved in the control of mood. Sessions last about 20 minutes and take place 3 to 5 times per week over a 6-week period. An anaesthetic is not required which is an advantage over ECT. The treatment can easily be given to outpatients, which is another advantage.
Deep Brain Stimulation (DBS)
A relatively new neurosurgical treatment called Deep Brain Stimulation (DBS) can help patients for whom antidepressant treatment and ECT have been unsuccessful. PET (positron emission tomography) scan studies have shown that there is increased metabolism in a specific area of the brain (called BA25) in depressed patients. When a patient recovers from depression the metabolic activity in this area reduces. There are many connections from area BA25 to other parts of the brain, including areas we know are important in regulating sleep and appetite. DBS is focused on stimulating area BA25 to reduce the metabolism in that area.
During the procedure patients are awake when the tiny electrode is inserted. Patients are shown different pictures, which generate different emotional responses. After 3 months of stimulation the metabolic abnormality is corrected. It is not understood why some patients benefit and some don't. There are on going randomised controlled trials in North America at the moment. In general there is a 60% remission rate. DBS has been shown to be as effective as Cognitive Behaviour Therapy with SSRI antidepressant treatment when both treatments have been assessed using PET scanning to measure changes in regional brain activity.
Although this treatment is not used very often it is important for doctors in general to know that it exists and that it can produce excellent results in patients who have had treatment failures with all of the other options described above.