Depression

Major depression is one of the most common mood disorders and can lead to suicide, which is the ninth leading cause of death in the United States.

It has been established that suicide is committed by about 15% of patients with severe depression, including patients with major depression and depression within the framework of bipolar disorder. Depression is also an independent risk factor for disability in patients who have suffered a myocardial infarction and stroke. The quality of life of patients with major depression or depressive symptoms that do not meet the criteria for major depression (subsyndromal depression) is significantly lower than that of healthy individuals and patients with other chronic pathologies.

Affective disorders are one of the main sources of human distress and disability and represent a serious medical and social problem. Major depression alone causes economic damage exceeding $43 billion annually, of which $12 billion is spent on treatment, $23 billion are losses associated with absenteeism and lost production, and $8 billion are losses caused by early death due to suicide. We should not forget about the losses associated with a decrease in the quality of life of these patients, which cannot be assessed. Affective disorders include major depression, dysthymia, bipolar disorder (manic-depressive psychosis), cyclothymia, and affective disorders caused by somatic and neurological diseases. The relatively high prevalence of affective disorders makes them a pressing issue for all practicing physicians.

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Symptoms of Depression

The core symptoms of major depression include depressed mood, anhedonia, changes in appetite, sleep disturbances, psychomotor agitation or inhibition, fatigue, difficulty concentrating, indecisiveness, and recurrent thoughts of death and suicide. A diagnosis of depression can be made if at least five of these symptoms are present for two or more weeks. In addition, other possible causes of these symptoms, such as bereavement, medication, or another medical condition that can cause depression, must be ruled out. Contrary to popular belief, suicidal behavior is not an obligatory sign of depression.

Over the past few years, the cumulative prevalence of depression (that is, the proportion of people diagnosed with it during their lifetime) has stabilized, but the average age of onset has decreased significantly. Depression is chronic in approximately 50-55% of people, and at the onset of the disease it is impossible to determine whether this will be the only depressive episode. If a second episode has developed, the probability of a third is 65-75%, and after the third episode, the probability of a fourth is 85-95%. Usually after the third episode, and sometimes after the second episode if it was particularly severe, most doctors consider it necessary to prescribe long-term maintenance therapy.

Diagnostic criteria for major depressive episode

• Five (or more) of the following symptoms, characterized by a deviation from the usual state, are simultaneously present for at least 2 weeks; one of these symptoms must be either

1. depressed mood, or
2. loss of interest or sense of pleasure

Note: Symptoms that are clearly caused by somatic or neurological diseases or by delusions and hallucinations not associated with an affective disorder should not be included.

• A depressed mood that is noted for most of the day, almost every day, by the patient themselves (for example, as a feeling of sadness or emptiness) or by those around them (for example, by the patient's sad appearance).

Note: Children and adolescents may experience irritability.

• Marked loss of interest and pleasure in all or almost all activities for most of the day nearly every day (as reported or observed by others)
• Marked weight loss (not caused by dieting) or weight gain (for example, a change in weight of more than 596 in one month), or a decrease or increase in appetite almost daily.

Note:

In children, it is necessary to take into account the decrease in weight gain in relation to the expected one.

• Insomnia or lshersomnia almost daily. Psychomotor agitation or retardation almost daily (as observed by others, not just subjective feelings of restlessness or slowness)
• Fatigue or loss of energy almost daily
• Decreased ability to think or concentrate, or indecisiveness almost daily (as perceived by subjective feelings or observations by others)
• Recurrent thoughts of death (not limited to fear of death), recurrent suicidal ideation without specific plans for suicide, or a suicide attempt or specific plan for carrying it out
• Symptoms do not meet criteria for a mixed episode
• Symptoms cause clinically significant discomfort or disrupt the patient's life in social, professional or other important areas
• Symptoms are not caused by direct physiological effects of exogenous substances (eg, addictive substances or drugs) or a general disease (eg, hypothyroidism)
• The symptoms cannot be explained by a reaction to a severe loss; for example, after the loss of a loved one, the symptoms persist for more than 2 months or are characterized by marked functional impairment, a morbid belief in one's own worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation.

Many patients, especially in general medical practice, do not complain of depression as such or of a depressed mood, but rather of one or another symptom, often associated with physical ill-being. In this regard, depression should always be kept in mind when examining a patient presenting with somatic complaints. Symptoms of depression develop gradually, over many days or weeks, so it is impossible to pinpoint the exact time of its onset. Often, friends, relatives, and family members notice ill-being earlier than the patient himself.

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Diagnostic criteria for melancholia

Diagnostic criteria for melancholia within a major depressive episode in major depression or a recent depressive episode in bipolar I or II disorder

• Presence of at least one of the following symptoms at the height of the current episode:
• Lack of pleasure in all or almost all activities
• Indifference to everything that is usually pleasant (the patient does not feel significantly better, even temporarily, if something good happens to him)
• Presence of at least three of the following symptoms:
• Depressed mood has a special character (for example, depressed mood is experienced as something different from the feelings experienced when losing a loved one)
• Depression symptoms regularly worsen in the morning
• Early morning awakenings (at least 2 hours before usual time)
• Severe psychomotor retardation or, conversely, agitation
• Severe anorexia or weight loss
• Excessive or inappropriate feelings of guilt

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Diagnostic criteria for catatonia

Diagnostic criteria for catatonia in a major depressive episode, a manic episode, or a mixed episode in major depression and bipolar I or II disorder

• Predominance of at least two of the following symptoms in the clinical picture:
• Motor immobility, manifested by catalepsy (with the development of waxy flexibility) or stupor
• Excessive motor activity (i.e. apparently purposeless movements that do not change in response to external stimuli)
• Extreme negativism (clearly unmotivated resistance to any instructions, maintaining a rigid posture despite anyone's attempts to change it) or mutiem
• Peculiarity of voluntary movements, manifested in posture (voluntary adoption of an inappropriate or bizarre posture), stereotypical movements, pronounced mannerisms or grimace
• Echolalia or echopraxia

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Diagnostic criteria for atypical depression

• Mood reactivity (i.e., improvements in mood in response to real or perceived positive events)
• Two or more of the following symptoms:
• Marked increase in body mass or increased appetite
• Hypersomnia
• A feeling of heaviness or unwieldiness in the arms and legs
• Vulnerability to rejection from other people (not limited to episodes of affective disorders), leading to disruption of the patient's life in the social or professional spheres
• The condition does not meet the criteria for melancholia or catatonic symptoms during the same episode

These criteria apply if the specified symptoms have been predominant in the last 2 weeks of a major depressive episode in major depression or the most recent major depressive episode in bipolar I or II disorder, or if the specified symptoms have been predominant in the last 2 years in dysthymia.

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How to inform a patient about a diagnosis of depression?

When a patient is diagnosed with depression for the first time, there are a number of issues to discuss with him. Many patients who have not previously consulted a psychiatrist do not even suspect that they have a serious mental disorder. They understand that they are not in good health, but they do not perceive it as a disease and often complain of individual symptoms. In order to create optimal conditions for the patient, it is important to understand what impact affective disorders can have on the patient's relationships with his family and loved ones. The patient, and if possible, his relatives and loved ones, should be informed that depression is an illness and not a manifestation of weakness of character. Many families do not understand what caused such frightening changes in their loved one and expect that he will get better as soon as he makes an effort. Therefore, it is important to inform the patient and his family about the specifics of the disease. In addition, without frightening the patient, it is necessary to discuss with him the possible side effects of the drugs that will be prescribed to him and the measures that should be taken if they occur.

Key questions to discuss with a patient when diagnosing major depression

• Characteristics of the symptoms of the disease
• Depression as a common disease
• Depression is a disease, not a weakness of character
• Neurovegetative disorders are a harbinger of high effectiveness of antidepressants
• Characteristics of the main side effects of treatment

Differential diagnosis of depression

The differential diagnosis of major depression should be made with other affective disorders, in particular dysthymia and, most importantly, with bipolar affective disorder (BAD). Approximately 10% of patients with major depression subsequently develop BAD; accordingly, the prevalence of BAD is about 1/10 of the prevalence of major depression. The differential diagnosis of major depression with BAD is especially relevant in young patients. In addition, differential diagnosis should be made with schizoaffective disorder, schizophrenia, dementia, dependence on psychotropic substances (both prescribed and illegal), as well as conditions arising from somatic or neurological diseases.

If psychotic symptoms are present along with the symptoms of major depression, neuroleptics or electroconvulsive therapy (ECT) should be added to antidepressant therapy. Atypical manifestations such as increased appetite, often with a strong craving for high-carbohydrate foods and sweets, drowsiness, heaviness in the limbs, anxiety, paradoxical mood swings during the day, intolerance to refusals require the prescription of drugs that enhance serotonergic activity or monoamine oxidase inhibitors. Melancholia is manifested in the fact that a person stops enjoying most activities and becomes indifferent to what previously brought joy. Patients with symptoms of melancholia cannot “cheer up” even for a short time. Other manifestations of melancholia in major depression include a feeling of oppression, mood swings during the day with morning intensification of depressive symptoms, early morning awakenings, psychomotor retardation or agitation, anorexia or weight loss, and excessive guilt. In depression with psychotic symptoms, delusions and hallucinations may be congruent in content with affective symptoms or, conversely, incongruent (not coinciding in content with depressive motives). Catatonic symptoms are characterized by psychomotor disturbances, negativism, echolalia, and echopraxia.

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The Link Between Crime and Depression

The relationship between depression and crime is less well understood than the relationship between schizophrenia and crime. According to an Office for National Statistics review of mental disorders in prisons, schizophrenia and delusional disorders are more common than affective disorders.

Depression and mania can directly lead to crime. Although any type of crime can be committed as a result of an affective disorder, there are a number of well-known associations:

Depression and Murder

Severe depression can cause the subject to think about the hopelessness of existence, the lack of purpose in life, and therefore the only way out is death. In some cases, homicide can be followed by suicide. In different studies, the suicide rates after homicide vary. According to West, a significant proportion of suicides are associated with an abnormal mental state of the subjects, and depression plays a significant role here.

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Depression and infanticide

In such cases, the murder of a child may be directly related to delusions or hallucinations. On the other hand, the act of violence may be a consequence of irritability due to an affective disorder.

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Depression and theft

In severe depression, there are several possible links to theft:

• stealing can be a regressive act, an act that brings comfort;
• theft may be an attempt to draw attention to the subject's misfortune;
• This act may not be a real theft, but rather a manifestation of absent-mindedness in a disorganized state of mind.

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Depression and arson

In this association, arson may be an attempt to destroy something due to a feeling of hopelessness and despair, or arson may, through its destructive effect, relieve the subject's state of tension and dysphoria.

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Depression, Alcoholism and Crime

Long-term alcohol abuse can lead to depression, or depression can lead to alcohol abuse. The disinhibiting combination of alcohol and depression can then lead to crime, including sexual crime.

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Depression and Explosive Personality

People with personality disorders often find themselves less able to cope with their depressed states. The tension that arises from the discomfort of depression may be followed by violent outbursts or destructive behavior.

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Depression and teenage criminals

In this association, depression may be masked. Externally, there may be theatrical behavioral traits, as well as manifestations of behavioral disorder, expressed, for example, in constant theft. In the past, there is usually a history of normal behavior and the absence of personality deviations.

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Depression alleviated by crime

Some authors draw attention to the phenomenon of depression and tension that are relieved by committing an act of violence. The history of depression is traced to the committed criminal act, and then the subject's depression disappears. From a clinical point of view, this is most often noted in subjects with personality disorders.

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Manic states and crimes

In mania, the patient may experience states of rapture with hallucinations or delusions of grandeur, which may lead to the commission of a crime. The combination of weak criticism of one's condition and substance abuse may lead to behavior that violates social norms in mania.

Medical and legal aspects of depression

Major mood disorders are grounds for the psychiatric illness defense and psychiatric recommendations. In severe cases, especially mania, the disorder may be so severe that the subject is unable to participate in the trial. In homicide cases, a plea of diminished responsibility is appropriate, and if delusions and hallucinations are present, the subject may fall under the McNaughten Rules. Which hospital will accept the patient depends on the degree of violence, willingness to cooperate with therapists, and determination to repeat the previous offense.