First Glance

Interview Most patients suffering from depression are first seen by a Family Physician in the community. A FP asking a qualified Psychiatrist for some tips in the management of depression in an outdoor setting is presented.

FP: Doctor, Whom should we call a patient suffering from clinical depression in need of treatment? What are the presenting symptoms?

Psy: While for a lay person it could be defined as feeling sad or "down and under", since you are a doctor, let me give you a table which you can paste and refer to whenever necessary: The following is the list of symptoms you must ask from a patient for diagnosing depression:

Sleep: Disturbed. The patient gets up earlier than his actual wakeup time.

Appetite: Loss of appetite but in some cases appetite may increase.

Weight Loss: Is common but opposite can happen.

Diurnal Variation: Feeling low and sad in the morning and as the day passes starts feeling better. In the evening as the sun goes down the patient again feels depressed.

Loss of Libido: Reduced sexual desire is common. In some cases sexual problems like pre-mature ejaculation may increase.

Psychomotor Retardation: Individual's thinking as well as motor activity reduces. He does not feel like doing anything in life. Sometimes even routine work becomes unmanageable.

Mood: Sad. Does not feel like talking to anybody. Loses interest in previously pleasurable activities like watching TV or attending parties.

Crying Spells: Individual becomes very sensitive and starts crying without any obvious reason.

Suicidal Ideas: Preoccupation with death is common.

Physical Symptoms: Vague pains, headache, pain in chest and constipation may be present. Anxiety symptoms like tremors, palpitation, giddiness, dryness of mouth are also seen in depression.

Delusions: Are rare in depression but sometimes patients may get nihilistic or have somatic delusions. For example, they are going to die or the world is coming to an end.

FP: Are there any specific types of depression?

Psy: Yes. If a woman goes into depression after delivery, it is called Post-partum depression. If a woman gets depression around menopause or a male gets it around his retirement time, it is called Involutional depression.

FP: Do children also suffer from depression?

Psy: I am glad you asked that question. Yes, in fact, depression in children is on the increase although at one time it was thought the children were spared this disease.

FP: What are the symptoms of depression in children?

Psy: Children can present with scholastic backwardness, bed-wetting, hyperactivity, antisocial behaviour and at times may refuse to attend school. It is extremely important to diagnose depression early in children.

FP: Please explain the treatment of depression?

Psy: There are various approaches to the treatment but the commonest and simplest so far, for a FP at his clinic remains the antidepressant oral drugs. The most widely prescribed drugs are tricyclics like imipramine, amitriptyline, dothiepin etc. The dosage ranges from 50-200 mg/day. Most of the patients respond to approximately 75-150 mg/day. There may be adverse effects such as dryness of mouth, constipation, mild postural hypertension, tremulousness etc. The antidepressant effect begins after the second week. This fact needs to be explained to the patient and the relatives. Of the newer drugs, fluoxetine is promising. The dosage is 20-60 mg/day. It can be given during the day, as it does not cause sedation. Depressive symptoms should subside after 4-8 weeks but the drug needs to be continued at least for 6 months. This also depends on the individual patient. The entire treatment needs to be supervised by a close relative. Any deterioration should be immediately reported by the relative either to you or to the treating psychiatrist.

FP: We all know that suicide is the only major serious possibility if a patient is neglected. How do we recognize such symptoms in their early stage?

Psy: Besides the symptoms mentioned before, a threat to commit suicide should be the earliest danger sign. An attempt is clearly diagnostic and necessitates a visit to a psychiatrist or a counsellor.

FP: Thank you doctor, now I feel far more confident about treating patients with depression in my clinic.