(A) Clinical manifestations of depression
Depression is clinically characterized by depressed mood, slowed thinking, reduced volitional activity and somatic symptoms.
1, depressed mood is mainly manifested as significant and persistent depressed mood, depression and pessimism. Patients spend their days worried, depressed, sad, long and short sighs. Patients with milder degree of depression feel sullen, no sense of joy, lack of interest in everything, usually very hobby activities such as watching soccer games, playing cards, planting flowers and plants do not feel boring, anything can not bring up the energy, feel “heart resentment and depression”, “happy not up “Patients often complain that “there is no point in living” and “it’s hard to feel happy”. Some patients may have anxiety and agitation symptoms, especially in menopausal and elderly depressed patients.
In typical cases, the depressive state of mind is characterized by a morning-heavy and night-light rhythm, i.e., the depressed mood is more severe in the morning and can be reduced in the evening, which can help in the diagnosis if it occurs. Under the influence of low mood, the patient has a low self-esteem, feels inferior to everything, and blames himself for all the faults. Self-confidence decreases, often generating a sense of uselessness, hopelessness, helplessness and worthlessness, feeling that they are incapable and incompetent, feeling that they have dragged down their families and society; looking back on the past, accomplishing nothing and having a sense of guilt for past unimportant and dishonest behavior; thinking about the future, feeling that the future is bleak, foreseeing that their jobs will fail, their finances will collapse, their families will have misfortunes, and their health will inevitably deteriorate.
On the basis of pessimism and disappointment, there is a feeling of isolation, accompanied by self-blame and self-sin. In severe cases, delusions of guilt may appear; on the basis of physical discomfort, suspicion of illness, suspicion of terminal illness, etc.; there may also be a relationship, delusions of victimization, etc. Some patients may also experience hallucinations.
Patients feel that their brains are slow to react, their thinking is slow, their reactions are slow, their thoughts are closed, and they feel that “their brains are like a rusty machine, their brains are like a layer of paste that cannot be opened”. The clinical manifestation is the reduction of active speech, the speed of speech is significantly slowed down, the voice is low, the patient feels that the brain can not be used, it is difficult to think about problems, and the ability to work and study is reduced.
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 and interact with people around, often sit alone, or lie in bed all day, do not want to go to work, do not want to go out, do not want to participate in activities and hobbies that they usually like, often closed door and live alone, distant from friends and relatives, avoid social interaction. In severe cases, the patient may not even care about eating, drinking, or personal hygiene, or even develop into a state of silence, immobility, or inappetence, which may be 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, rubbing hands and feet or pacing around. Patients with severe depression are often accompanied by negative suicidal ideation or behavior. Negative pessimistic thoughts and feelings of self-blame and guilt can lead to desperate thoughts, thinking that “ending one’s life is a relief” and “one is redundant in the world”, and can promote planning for suicide and develop into suicidal behavior. This is the most dangerous symptom of depression and should be vigilant. Long-term follow-up has found that about 15% of depressed patients eventually die by suicide. The idea of suicide usually arises gradually, the lighter the person only feels that life is meaningless and not worth staying, the idea of sudden death gradually arises, and as depression increases, the idea of suicide becomes stronger and stronger, trying to end oneself by all means.
4.Somatic symptoms Very common, mainly sleep disorders, loss of appetite, weight loss, loss of libido, constipation, pain in any part of the body, impotence, amenorrhea, weakness, etc. The complaints of somatic discomfort can involve all organs. Symptoms of autonomic dysfunction are also more common. 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 the diagnosis of depressive episodes. Some of them show difficulty in falling asleep and not sleeping deeply; a few patients show excessive sleep. Weight loss is not necessarily proportional to appetite loss, and a few patients may appear as increased appetite and weight gain.
5, other depressive episodes can also appear depersonalization, reality dissociation and obsessive-compulsive symptoms. Depressive episodes with mild clinical manifestations are called mild depression. The main manifestations are depressed emotion, loss of interest and pleasure, easy fatigue, self-consciousness of daily work and social skills are reduced. In addition to depression, most patients with geriatric depression have prominent anxiety and irritability, which can sometimes be characterized by irritability and hostility. Psychomotor retardation and somatic complaints are more pronounced than in younger patients.
The symptoms of cognitive impairment may be more pronounced due to significant delays in thought association and memory loss, and may resemble dementia, such as decreased ability to calculate, remember, understand, and judge. Somatic complaints are more common in the gastrointestinal tract, such as loss of appetite, bloating, constipation, etc., and are often entangled with a physical complaint, and are prone to hypochondriasis, which can develop into suspicion, nihilism and delusions of guilt. The course of the disease is lengthy and easily develops into chronic.
(B) Treatment of depression
Antidepressants are the main drugs used in the treatment of depressive disorders and can effectively relieve depressive moods and accompanying anxiety, tension and physical symptoms, with an efficiency of about 60% to 80%. Although the maintenance medication of antidepressants can prevent the relapse of depression to a certain extent, it cannot prevent the shift to manic episodes.
Severe depression requires the addition of small doses of antipsychotic drugs.
1.Commonly used antidepressants
(1) Selective 5-HT reuptake inhibitors (SSRIs): currently in clinical use are fluoxetine, paroxetine, sertraline, fluvoxamine (fluvoxamine), citalopram. As the half-life of SSRIs are long. Most of them are in the range of 18 to 26 hours . Only one dose per mouth is needed. Adverse effects of SSRIs are few and mild, especially anticholinergic and cardiac adverse effects. Common adverse reactions include nausea, vomiting, anorexia, constipation, diarrhea, dry mouth, tremor, insomnia, anxiety, and sexual dysfunction, with occasional rash and, in a few patients, mild mania. It cannot be used in combination with MAOI.
(2) Norepinephrine (NE) and 5-hydroxytryptamine (5-HT) dual uptake inhibitors (SNRIs): SNRIs are sure to have a fast onset of action and have obvious antidepressant and anxiolytic effects. They are also effective in refractory cases. The main ones are venlafaxine, immediate release in 2 to 3 doses, and extended release in capsules, taken once a day. Common adverse reactions include nausea, dry mouth, sweating, fatigue, anxiety, tremor, impotence and ejaculation disorders. Adverse reactions occur with high doses when blood pressure may be mildly elevated in some patients. No specific contraindications; should be used with caution in patients with severe liver and kidney disease, hypertension, and epilepsy. Cannot be used in combination with MAOIs;
(3) NE and specific 5-HT antidepressants (NaSSAs): Mirtazapine is the representative drug, has good antidepressant, anxiolytic and improve sleep effect, oral absorption, fast onset of action, small anticholinergic effect, sedative effect, on sexual function, almost no effect. Take it at night. Common adverse reactions are sedation, sleepiness, dizziness, fatigue, appetite and weight gain.
(4) Tricyclic and tetracyclic antidepressants: Mipramine (promethazine), Clomipramine (chlorpromazine), Amitriptyline and Doxepin (Doxepin) are tricyclic antidepressants commonly used in clinical practice, mainly for the acute phase and maintenance treatment of depression, with an overall efficiency of about 70%. Clinical use should start with a small dose and gradually increase, with an effective therapeutic dose of 150-300mg/day. The effective therapeutic dose is 150-300mg/day, divided into 2-3 oral doses, and can also be taken once a night after meals or before bedtime. Generally, the drug takes effect 2-4 weeks after administration. If there is no significant effect after 4-6 weeks of using the treatment dose, a change of medication should be considered.
Tricyclic antidepressants have more adverse reactions, mainly anticholinergic and cardiovascular adverse reactions. Dry mouth, drowsiness, constipation, blurred vision, difficulty urinating, tachycardia, postural hypotension and heart rate changes are common. The dose of the drug should be reduced in elderly and frail patients, and supervision should be paid attention to when necessary. It should not be used in patients with pre-existing cardiovascular disease. Meptyline is a tetracyclic antidepressant, its antidepressant effect is similar to tricyclic drugs, also has a significant sedative effect, the effective therapeutic dose is 150-250mg/day, adverse reactions are less, mainly dry mouth, drowsiness, blurred vision, skin rash, weight gain, etc., occasionally can cause seizures.
(5) monoamine oxidase inhibitor (MA01): new monoamine oxidase inhibitor morpholino (moclobemide) is a reversible, selective monoamine oxidase A inhibitor, it overcomes the non-selective, non-reversible MAOI hypertensive crisis, hepatotoxicity, antidepressant effect and mipramine equivalent, the effective therapeutic dose is 300~600mg/day, the main adverse effects include nausea, dry mouth, constipation, blurred vision and tremor.
(6) Other antidepressants: trazodone, tianeptine, etc. have good antidepressant effects.
(7) Severe cases can be added with antipsychotic drugs, and the applied dose should be small.
2.Electroconvulsive therapy and modified electroconvulsive therapy
For depressed patients with obvious psychosocial factors, psychotherapy is often combined with drug treatment. Supportive psychotherapy helps patients to understand and treat their illness correctly and cooperate with treatment actively through listening, explanation, guidance, encouragement and comfort. A series of therapeutic techniques such as cognitive therapy, behavioral therapy, interpersonal psychotherapy, marriage and family therapy can help patients identify and change cognitive distortions, correct maladaptive behaviors, improve patients’ interpersonal skills and psychological adaptation, and increase patients’ satisfaction with family and marital life, which can reduce or alleviate patients’ depressive symptoms, mobilize patients’ motivation, correct their poor personalities, and improve patients’ problem-solving ability and ability to cope with handling stress, save patients’ medical expenses, promote recovery, and prevent relapse.
(C) Relapse prevention
For patients with the first depressive episode and clinical remission by medication, most scholars believe that the maintenance treatment time should be 6 months to 1 year; for the second episode, maintenance treatment is recommended for 3-5 years; for the third episode, long-term maintenance treatment should be given; the dose of medication for maintenance treatment is considered by most scholars to be the same as the treatment dose, and some scholars believe that it can be slightly lower than the treatment dose. However, patients should be asked to follow up regularly.
Psychotherapy and social support systems also play a very important role in relapse prevention. Patients should be relieved or relieved of excessive psychological burden and stress as much as possible, and patients should be helped to solve practical difficulties and problems in life and work, to improve their coping ability, and to actively create a good environment for them in order to prevent relapse.