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Diagnosis

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Depression – An overview
- Dr Amit Desai,
Consulting Psychiatrist,Mumbai

2. Bipolar Disorder

This disorder is characterized by a recurring pattern of both depressive and manic episodes. The following three types of bipolar disorder are described.

Bipolar disorders, Manic Type: The current episode fulfills the criteria for a manic episode (Table 2) and there must have been previous episodes of either mania or depression.

Bipolar Disorders, Depressed Type: This disorder is characterized by the occurrence of one or more manic episodes in the past while the current episode fulfils the diagnostic criteria for a depressive episode.

Bipolar Disorder, Mixed Type: For the diagnosis of this disorder, DSM-III R requires the occurrence of either complete manic and depressive episodes, each lasting for at least one day or the rapid alternation of both these states every few days

3. Dysthymia

This type of depressive disorder is characterized by a chronic rather than an episodic occurrence of depressive symptoms. This disorder is viewed as a less severe form of major depression. The diagnostic criteria for dysthymia are shown in Table 4.

Table 5

Diagnostic Criteria for Cyclothymia

For two years, presence of numerous hypomanic episodes (all of the criteria for a manic episode, except criterion C that indicates marked impairment) and numerous periods with depressed mood or loss of interest or pleasure that did not meet criterion A or major depressive episode.

During a two year period of disturbance, never without hypomanic or depressive symptoms for more than two months at a time

No clear evidence of major depressive episode or manic episode during the first two years of the disturbance

Not superimposed on a chronic psychotic disorder (e.g. schizophrenia ).

It cannot be established that an organic factor initiated and maintained the disturbance

4. Cyclothymia (Table 5)

This disorder is considered to be milder form of bipolar disorder. Cyclothymia patients could present with all the symptoms of a bipolar disorder but they are neither as severe nor are they of sufficient duration to fulfil the diagnostic criteria for a bipolar disorder.

PROGNOSIS

Approximately 70% of all patients of major depression have a second depressive episode. The risk of recurrence is increased by alcohol and drug abuse, anxiety symptoms and co-existing personality defects. Approximately half of all patients are mentally healthy at long-term follow up while another 30% have moderate impairment in their mental functioning. Significant and chronic impairment in functioning is seen in 20% of all patients with major depression.

Bipolar disorders have a worse prognosis than major depression. Short duration of manic episode, older age of onset and fewer co-existing personality problems weigh towards a better prognosis. On long-term follow up, 15% of all bipolar disorder patients are asymptomatic while another 45% are well but have had multiple episodes. 30% of patients are in partial remission and 10% are chronically ill.

The prognosis for dysthymic and cyclothymic patients is generally not good. Approximately 25% of all dysthymic patients may not attain complete recovery, where as about 40% of all cyclothymic patients go on a bipolar disorder.

Table 6
Antidepressant Drugs Available in India
Tricyclic Antidepressants Dothiepin Imipramine Amitriptyline Doxepin Clomipramine Nortriptyline Nitroxazepine Amineptine Teracyclic Antidepressant Mianserin Amoxapine Serotonin re-uptake Inhibitors Fluoxetine	Triazolopyridine Derivatives Trazodone Benzodiazepines Alprazolam Miscellaneous Thioridazine Flupenthixol Drugs used in Prophylaxis of Mood Disorders Lithium Carbonates Carbamazepine Sodium Valproate

TREATMENT:

The first decision a clinician must take is whether to hospitalise a patient or to institute treatment on an out-patient basis. Indication for hospitalisation of patients with mood disorders are as follows :

Imminent danger of suicide or homicide.
Grossly reduced ability to take care of self
Absence of usual social support systems, e.g. family & friends.

Electroconvulsive therapy is the treatment of choice in depressed patients who are strongly suicidal. Additionally, depressive disorder with prominent delusions or with features of melancholia are also very responsive to electroconvulsive therapy. Antidepressant drugs, listed in Table 6, are the mainstay of the therapeutic regimen. It is essential that pharmacotherapy is combined with counseling or any other type of psychotherapy for obtaining optimum results. Antidepressant treatment of depressive disorders generally rewarding for the psychiatrist. The prognosis for each episode of either mania or depression is good. Therefore, optimism is always warranted and is generally welcomed by both the patients and their family members.

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