Educationals

Major depression can also occur after minimal trauma both in the presence or in the absence of object signs of brain injury.

Depression is the most common emotional reaction to head injury.

Depression occurring after head injury may be related to the patient's insight to the cognitive and physical disability due to the trauma, the pre-morbid personality, and the family and social support systems during recovery.

The features may be those of a "reactive" depression. Anorexia and insomnia may be present. The depression responds to changes in activity and environment. The patient complains of difficulty with concentration and minor defects of forgetfulness and irritability. There are paranoid and hypochondriacal symptoms, a fluctuating headache, marked anxiety and depression and neurasthemic symptoms, the patient constantly complains of excessive mental and physical fatigue. The symptoms may last for many months after the injury.

Rapid cycling bipolar illness where alternate elation and depression lasting only for a few hours a day has been reported after closed head injury. No definite relationship can be demonstrated between the severity and site of trauma and the psychological symptoms.

Chances of death by suicide is considerably increased after head injury, accounting for 14% of all deaths. The factor responsible for suicide include financial difficulties, family quarrels due to disability, marital problems, difficulties in adjustment, difficulties in interpersonal relationships, excessive drinking etc. Significantly, a change in the character of the person, after the injury has been observed in 40% of patients who committed suicide.

Huntington's Chorea and Depression

Psychiatric changes may be present for some time before the onset of involuntary movements or intellectual impairment

There is a change in personality. The patient becomes morose, slow, apathetic, quarrelsome, neglectful and paranoid.

The anxiety and depression may be apparent right at the outset and may be ascribed to some depression event.

The depression can be severe in the early stages when the patient still retains insight. Later on the mood becomes apathetic, self neglect and euphoria replace the depression.

The incidence of affective disorders has been reported to be as high as 41%, the depression predating the chorea by 2 to 20 years in 66% of the cases.

Depression can be severe and suicide is a definite risk. In some reported series of 102 patients, 10 attempted suicide while 13% self mutilated.

The depression responds to antidepressant drugs and electroconvulsive therapy.

Systemic Lupus Erythematosus and Depression

The functional psychoses in SLE can be depressive, schizophrenia like, or rarely, manic.

Chronic psychotic depression is commoner than schizophrenia like states.

Neurotic reactions in the form of anxiety and depression can also occur. The depressive reaction starts gradually, lasts several weeks or months and resolves slowly.

The cause of the functional symptoms is obscure, their reversibility and recurrence suggests that they may be related to the disease process. On the other hand they may be in response to the psychosocial stress due to the illness. The vasculities and ischaemia can result in symptoms of confusion or dementia.

Steroids which are the mainstay of treatment in SLE can precipitate or aggravate the mental symptoms. These may respond to a reduction in dose of the steroids.

A patient in remission who is on steroid medication may develop depressive psychosis. The steroid could be gradually withdrawn, monitoring DNA antibodies at the same time. The titre falls if the disease is suppressed. A high titre or rising titre when the patient is on steroids will help to differentiate whether the psychosis is due to the disease itself or due to the steroids.

Immunosuppresive drugs like cylcophosphamide and azathioprine can be tried instead of steroids. Antidepressants and E.C.T. can be used for treating the depression