Depression, also known as depressive disorder, is characterized by significant and persistent depression and is the main type of mood disorder. The depressed mood can range from sullenness to grief, low self-esteem and depression, or even pessimism and anxiety, and may include suicide attempts or behaviors; some cases may have significant anxiety and motor agitation; severe cases may have hallucinations, delusions and other psychotic symptoms.
Each episode lasts at least 2 weeks, or even several years, and most cases have a tendency to have recurrent episodes, most episodes can be relieved, some may have residual symptoms or become chronic.
I. Common symptoms
Depressed mood, slowed thinking, reduced volitional activity, impaired cognitive function, and physical symptoms.
Etiology
To date, the etiology of depression is not clear, but it is certain that many biological, psychological and social environmental factors are involved in the pathogenesis of depression. Biological factors mainly involve genetic, neurobiochemical, neuroendocrine, and neuroregenerative aspects; psychological susceptibility qualities that are closely related to depression are pre-morbid personality traits, such as depressive temperament.
The exposure to stressful life events in adulthood is an important trigger for the development of clinically significant depressive episodes. However, these factors do not act in isolation, and the interaction between genetic and environmental or stressful factors, and the point at which this interaction occurs, are currently emphasized as having an important influence in the development of depression.
III. Clinical manifestations
Depression can be manifested as a single or repeated multiple depressive episodes, and the following are the main manifestations of depressive episodes.
1.Low mood
The main manifestation is significant and persistent depressed emotion, depression and pessimism. The lighter ones are sullen, unpleasant, and less interested, while the heavier ones are painful, pessimistic and desperate, and life is worse than death. The typical patient’s depressed state of mind has a rhythmical change of heavy morning and light night. On the basis of depressed mood, patients will have lower self-evaluation, a sense of uselessness, hopelessness, helplessness and worthlessness, often accompanied by self-blame and self-guilt, and in severe cases, delusions of guilt and paranoia, and some patients may have hallucinations.
2.Sluggish thinking
Patients have slow thinking, slow reaction, closed mind, and feel that “the brain is like a rusted machine” and “the brain is like a layer of glue”. Clinically, the active speech is reduced, the speed of speech is significantly slowed, the voice is low, and it is difficult to answer, and in severe cases, communication cannot be carried out smoothly.
3.Decreased volitional activity
The patient’s volitional activity is significantly and persistently inhibited. Clinical behavior is slow, life is passive, lazy, do not want to do anything, do not want to contact with the surrounding people, often sitting alone, or lying in bed all day, living alone behind closed doors, alienating friends and relatives, avoiding social interaction. In severe cases, the patient may even disregard physiological needs such as eating, drinking and personal hygiene, and may even develop into non-verbal, non-moving, and non-eating, which is called “depressive rigidity”, but on careful mental examination, the patient still shows painful depression.
Patients with anxiety may have symptoms such as fidgeting, finger grasping, hand rubbing or pacing around. Severe cases are often accompanied by negative suicidal ideation or behavior. Negative pessimistic thoughts and self-blame, lack of self-confidence can lead to desperate thoughts, thinking that “ending one’s life is a kind of relief”, “one is redundant in the world”, and can make suicide attempts develop into suicidal behavior. This is the most dangerous symptom of depression and should be vigilant.
4. Cognitive impairment
Studies have concluded that depressed patients have cognitive impairment. This is mainly manifested as decreased near memory, attention deficit, prolonged reaction time, increased alertness, poor abstract thinking, learning difficulties, poor language fluency, reduced spatial perception, eye-hand coordination and flexibility of thinking. Cognitive impairment leads to social dysfunction and affects the long-term prognosis of patients.
5.Somatic symptoms
The main symptoms include sleep disturbance, fatigue, loss of appetite, weight loss, constipation, pain in any part of the body, loss of libido, impotence, amenorrhea, etc. The physical complaints of somatic discomfort can involve all organs, such as nausea, vomiting, heartburn, chest tightness, sweating, etc. Symptoms of autonomic dysfunction are also more common. The complaints of pre-morbid somatic disorders are usually aggravated.
Sleep disorders mainly manifest as early awakening, usually 2 to 3 hours earlier than usual, and inability to fall back to sleep after waking, which is characteristic for depressive episodes. Some present with difficulty falling asleep and not sleeping deeply; a few patients present with excessive sleep. Weight loss is not necessarily proportional to appetite loss, and a few patients may have increased appetite and weight gain.
IV. Examination
For patients suspected of depression, in addition to a comprehensive physical examination and neurological examination, attention should be paid to ancillary examinations and laboratory tests. To date, there are no specific tests for depressive disorders. Therefore, current laboratory tests are mainly designed to exclude depression due to substance and somatic disorders. There are 2 laboratory tests of some significance, including the dexamethasone suppression test (DST) and the thyrotropin-releasing hormone suppression test (TRHST).
V. Diagnosis
The diagnosis of depression should be mainly based on medical history, clinical symptoms, disease duration and physical examination and laboratory tests, and the diagnosis of typical cases is generally not difficult. At present, the common international diagnostic criteria are ICD-10 and DSM-IV. ICD-10 is mainly used in China, which refers to the first episode of depression and recurrent depression, excluding bipolar depression. Patients usually have typical symptoms such as depressed mood, loss of interest and pleasure, low energy or fatigue.
VI. Other common symptoms are.
(1) Reduced ability to focus and pay attention.
(2) Decreased self-evaluation.
(3) Perceptions of self-guilt and feelings of worthlessness (even in mild episodes).
(4) Perception of a bleak and pessimistic future.
(5) Self-injurious or suicidal ideation or behavior.
(6) Sleep disturbances.
(7) Decreased appetite. The duration of the illness lasts at least 2 weeks.
VII. Treatment.
1. Treatment goals
The treatment of depressive episodes should achieve three goals.
(1) to improve the clinical cure rate and minimize the disability and suicide rates, with the key being the complete elimination of clinical symptoms.
(2) To improve the quality of survival and restore social function.
(3) Prevention of relapse.
2. Treatment principles.
(1) individualized treatment.
(2) Gradual increase in dose, using the smallest effective amount possible to minimize adverse reactions and improve compliance with medication.
(3) Adequate amount and full course of treatment.
(4) Single drug use as far as possible, if the efficacy is not good, consider switching treatment, booster therapy or combination therapy, but need to pay attention to drug interactions.
(5) Informed notification prior to treatment.
(6) Close observation of changes and adverse effects during treatment and timely management.
(7) Combination of psychotherapy to increase the efficacy.
(8) Active treatment of other physical diseases, substance dependence, anxiety disorders, etc. that are co-morbid with depression.
3.Medication
Medication is the main treatment for depressive episodes above moderate level. At present, the first-line antidepressants mainly include selective 5-hydroxytryptamine reuptake inhibitors (SSRI, representing drugs fluoxetine, paroxetine, sertraline, fluvoxamine, citalopram and escitalopram), 5-hydroxytryptamine and norepinephrine reuptake inhibitors (SNRI, representing drugs venlafaxine and duloxetine), norepinephrine and specific 5-hydroxytryptaminergic antidepressants (NaSSA, representative drug mirtazapine), etc. Traditional tricyclic and tetracyclic antidepressants and monoamine oxidase inhibitors have been significantly reduced in application due to their large adverse effects.
4.Psychotherapy
For patients with depressive episodes with obvious psychosocial factors, it is often necessary to combine psychotherapy with pharmacotherapy. Commonly used psychotherapy methods include supportive psychotherapy, cognitive-behavioral therapy, interpersonal therapy, marriage and family therapy, psychodynamic therapy, etc. Among them, the efficacy of cognitive-behavioral therapy on depressive episodes has been recognized.
5.Physical therapy
Patients with severe negative suicidal attempts and those who have failed to be treated with antidepressants can be treated with modified electroconvulsive therapy (MECT). Maintenance treatment with medication is still required after electroconvulsive therapy. In recent years, a new physiotherapy treatment, repetitive transcranial magnetic stimulation (rTMS), has emerged, which is mainly applied to mild to moderate depressive episodes.
VIII. Prevention
A study of depression patients followed for 10 years found that 75% to 80% of patients had multiple relapses, so depression patients need preventive treatment. More than 3 episodes should be treated for a long time, even lifelong medication. Most scholars believe that the dose of maintenance medication should be the same as the treatment dose, and regular outpatient follow-up observations should also be made.
Psychotherapy and social support system also play a very important role in preventing relapse of the disease. Patients should be relieved or relieved of excessive psychological burden and pressure as much as possible, to help them solve practical difficulties and problems in life and work, to improve their coping ability, and to actively create a good environment for them to prevent relapse.