Q. What is the course of depression?
Ans. In depression self limiting course or spontaneous remission is known. But present views on depression have subtly shifted over the years. It is no longer viewed as ubiquitous trivial or transient, but as a "long term illness requiring long term management".
The long term course of the illness can be estimated from the fact that depression causes more disability than many chronic physical illnesses.78% of all patients will have a recurrence within the first 10 years, 30% within 1 year. Anywhere between 1-28% will experience chronicity of symptoms of which 15-20% will be due to non-response to treatment. In addition to this 56-62% will experience readmission to inpatient facilities and almost 13-15% of all depressive will meet their death by suicide.
Loss of productivity results both due to recurrences, chronicity as well as due to secondary psycho pathology like substance use disorders suicide attempts and accidents.
Q. Does depression require long term management?
Ans. Very often it is noticed that patient does not return to predepressive state. What comes as a further note of distress is the fact that illusion of benignity that has been conferred on depression has lead it to be underdiagnosed and undertreated.
In this context long term treatment would mean :
- Treatment beyond apparent response
- Treatment to produce and manage the early vulnerable periods
- Treatment which is adequate in terms of both dose and duration.
Despite this 15-20% of depressives do not recover. Almost 21% of all depressive show some form of chronic depressive symptoms for more than 2 years.
Q. What are the causes of poor outcome and incomplete recovery?
Ans. The causes include:
- Long duration of index episode
- Increased severity of the index episode
- Prior history of nonaffective psychiatric disorder
- Lower family income and support
- Old age
- Late treatment and more hospitalisations
- Longer duration of the illness
- Severe and continuous problems in life
Some of the explanations put forward for incomplete recovery include:
- Natural evolution of the illness.
- Inadequate doses of antidepressants.
- Uneven pace of recovery of symptoms.
- Accentuation of premorbid traits due to the illness.
Thus outcomes in depressive illness may range from full recovery to partial recovery to recurrence, to mortality due to suicide and other causes.
Q. How does one identify partial response?
Ans. Partial recovery may present itself in various guises. There may be a sub-syndromal chromal chronicity in the form of residual symptoms, neurotic symptoms or somatic complaints. Partial recovery may also present as social maladjustment. One of the most insidious presentations of depression is in the form of post-depressive personality change.
Depression may exist in sub-syndromal or residual state in the form of symptoms of emotional aridity or with an inability to from adequate emotional links with others. It may also present as chronic feelings of irreparable loss.
Q. Sometimes people show improvement in classical depressive conditions but exhibit some other symptoms unlike depression. Is this related to depression ?
Ans. Agoraphobic, phobic and conversion symptoms often represent underlying depression. Similar claims have been made for hypochondriasis and an obsessive brooding about past events. Occult depression presenting as somatic symptoms usually vague and ill defined have been suggested as a culture specific feature in some countries of the third world. Thus insomnia, headache, decreased libido, gastrointestinal symptoms and symptoms of neurosthenia, present together or along and not responding to appropriate clinical care should suggest the possibility of depression to a sensitised clinician. This would prevent over enthusiastic treatment with palliative medications especially of the sedative/hypnotic type.
A variation of residual symptoms among women is in the form of symptoms of clostrophobia, an unreasoning fear of calamity in the form of loss of one's spouse or mental illness or of loss of equilibrium.
This combination of decreased vitality, emotional aridity and pessimism can be crippling. The poignancy of this situation lies in its being eminently treatable.
Q. Some people seem to have problems of interpersonal adjustment, emotional distress and aggressive or irritable behaviour with dysphoric mood. Will you think of depression in these patients?
Ans. Depression may present as more covert social maladjustment occuring early in the illness but resolves slowly on treatment. This may lead to strained relationships with family and peers without any other overt symptoms.
More insidious are the personality changes which may present as a variety of traits ranging from orderly perfectionism to passive introverted '"Laziness" to histrionic attention seeking and egocentricism.
They are usually described as anxious, preoccupied, subject to frequent depressive spells and labouring under a rigid self imposed moral code .
The personality traits may be perceived as the accentuation of premorbid characteristics or as debilitating consequences to personality of a long term often recurrent illness.
Q. How do you prevent these complications arising out of depression?
Ans. Full recovery from depressive episode can be judged by improvement in patients quality of life. i.e. social interpersonal and occupational. It is important to note that patients report on 'feeling good' is better response but if patient reports that she/he is 'getting good' in terms of productivity in life it is the best response to the appropriate and adequate treatment.
The consequences or sequelae of depression is their preventable nature. The cure lies in extending the treatment of depression well beyond the point of symptomatic recovery and alleviation of the acute symptomatology. Premature discontinuation of antidepressants result in recurrence of symptoms in 50% of the patients in 1-4 months. Thus long term treatment implies both prophylactic treatment to prevent further full blown episodes as well as prevention of relapse in to subacute or chronic states.
Authorities recommend continuing treatment of depressive episodes for at least 4 to 6 months after symptomatic recovery. High index of suspicion for these sequelae and treatment with a well tolerated and safe antidepressant will have to remain a by ward in the treatment of depression. It's so traumatic to see patients having depression and they have to go through a very difficult stage of life.
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