I. Clinical manifestations
Depression can be manifested as a single or repeated multiple depressive episodes, 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 have diminished interest, 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 in the morning and light at 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 and association, slow reaction, closed thinking, 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 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 are 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 experience increased appetite and weight gain.
Treatment Editor
1.Treatment goals
The treatment of depressive episodes should achieve three goals.
(1) to improve the clinical cure rate and minimize the rate of disability and suicide, 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, the smallest possible effective amount, to minimize adverse effects, in order to improve compliance with the drug.
(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, representing the drug mirtazapine), etc. Traditional tricyclic and tetracyclic antidepressants and monoamine oxidase inhibitors have significantly decreased 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
In recent years, a new kind of physical therapy, repetitive transcranial magnetic stimulation (rTMS) therapy, has emerged, which is mainly applied to mild to moderate depressive episodes.