Reader's Corner

Asha Khanna had a tendency to lapse into episodes of apathy, listlessness and brooding. Mr Khanna had a massive heart attack and expired. Her family physician Dr Shah suspected that Asha would go into another fit of Depression and started her on therapy as well as counseling and thus prevented another episode.

Both these cases demonstrate the need of a dedicated as well as committed Physician to diagnose a case of Depression. As we saw in out last issue that Depression is of 2 types - Primary and Secondary. Largely being a Mood Disorder, causation and management of Depression depends on several factors. Let's peep into what all can influence this scourge of 20th century's FAST life.

Primary Depression or Involutional Depression as the name suggests is without any cause. But in reality even this type of Depression is influenced by the following factors.

• Heredity : Heredity does play an important role. Patients with +ve family history, either of Depression or other mental disorder, have a constitutionally determined predilection for Depression. 5% of the patients with Depression give a history of Schizophrenia in parents or in siblings. Family structure setup by such parents tends to foster abnormal reaction in children.
• Hormonal : Many women at about the involutional period experience various symptoms known as Menopause syndrome. In addition to physical symptoms there is melancholy, insommnia, difficulty in concentrating etc. This is due to decrease in ovarian hormone - estrogen. These patients, in most cases, give a history of either Pre Menstrual Syndrome or irregular menstrual cycle. Hormonal changes may play an interactive and aggravating role in involutional reactions, but they are not the primary causative factor. Another important hormone for a patient of Depression is that of Thyroid gland, as seen in case of Shalini. Hypothyroidism acts as an aggravating factor for those already pre-disposed to Depression.

Secondary or Reactive Depression due to

Ms Kamla had a childhood surrounded by sickness. Mother was a hypochondriac [2] and kept giving Kamla, painkillers for slightest pain. Commonest talk around the house was sickness, medicines and doctors. Kamla also turned out like her mother. All her symptoms were severe. She would go into depression just before menstruation and take a least 6 months to recover. Slightest stress would find Kamla down with a backache. Escape into bodily complaints did not last long, as all investigations were normal and doctors kept saying nothing is really wrong with her. Soon Kamla's stresses found escape in fits of depression.

This demonstrates how lack of resiliency, commonly present in most people can lead to depression. Patients with reactive depression lack this resiliency and have a personality predisposed to overreact to such stresses in life. Most of these patients reveal low ego strength together with a rigid conscience. This combination makes one prone to feeling guilty. Such patients are usually of timid disposition.

Many cases, on questioning, come out with repressed hostility towards loved ones, e.g. success of a sibling, unjustified action of a parent. Ashok hated his younger brother, who had become cynosure to all at home. He could do no wrong, whereas nothing Ashok did was ever right. They suppress this hostility because of its dangerous and unethical implications. This repression leads to hostile fantasies and then guilt. Ashok, also, being the elder one could not express his hostility and had to be supportive to his y o u n g e r brother. He had dreams of his brother dying in a road accident and then all realizing Ashok's worth. Now if the loved one is killed or seriously injured, the patient's normal feelings of grief are augmented by intense guilt as if those fantasies have brought about the tragedy. His brother actually met with an accident and passed away. Ashok, who had always felt he would be elated when alone, went into such severe depression that it took ECT[3] to bring him out. This attack came on because of a terrible feeling of guilt.

Immaturity and guilt go hand in hand. Immaturity is largely due to the failure of the family situation to complete socialization of the child, particularly with respect to eithical[4] and conscience development.

In some cases symptoms of Depression are used to force support and sympathy from others. These patients feel that their sympathy from others. These patients feel that their symptoms and hopeless situation is not being taken seriously enough and proper sympathy and appreciation for their desperate plight is not shown.

As was the case of Sheela, wife of Managing Director of a multinational company, who felt her husband had no time for her. To begin with she started complaining of bodily symptoms and received prompt attention from her busy, jet-set husband. Very soon he realized that these complaints had no basis and stopped sending her to doctors or inquire after her health. Sheela felt very low, alone and spent her days crying. This brought on renewed interest from her husband and for Sheela remained the only way to get attention from her husband.

In cases of chronic bodily ailments - loss of sleep, poor appetite, fatigue and irritability lower the general level of stress tolerance.

It can very easily be said that everything under the sun, every situation in life can lead to secondary depression.

What is required is