In terms of external manifestations, doctors evaluate depression as “three no’s” and “three self” symptoms, namely
① hopelessness, helplessness, worthlessness
② self-blame, self-criminalization, suicide; of course, there are other accompanying symptoms.
I. Clinical manifestations
The typical symptoms of depressive disorder include depressed mood, slow thinking, and reduced volitional behavior, also known as the “three low” symptoms. Among them, depressed mood is the core symptom, which can be morning heavy and evening light changes.
1.Low mood is also known as depressed state of mind
From mild mood, distraction, sadness, distress to pessimism and despair. It is manifested as listlessness and depression, complaining that life is meaningless, and there is no affection for loved ones, and the experience of anything, even things that make people happy, is painful and difficult. Against the background of depressed mood, the majority of patients have reduced self-esteem and self-confidence, which is also a characteristic symptom.
Many patients often have anxiety and tension symptoms, such as anxiety, fidgeting, constantly pacing back and forth, rubbing their hands, etc. Elderly depressed patients are often more prominent.
2. Decreased interest and lack of pleasure
Patients lose interest in daily activities, no sense of pleasure in activities that can be enjoyed, lack of emotional response to a pleasant environment, reluctance to participate in normal activities, such as parties, visiting friends and relatives, heterosexual interactions, etc., only a few aspects at first, later developed to all activities do not participate, including interaction with family members, closed door and solitary, alienation of friends and relatives, avoidance of social interaction, behavior withdrawal. Low sexual desire, lack of pleasure or no demand for sex, patients often describe their condition as “no feelings”, “become numb”.
3.Loss of energy or energy
The patient’s energy decreases significantly and the fatigue continues without any reason. At first, they feel low energy, tired and weak, passively and mechanically participating in some daily activities, and as their condition worsens, they become more listless, feel overwhelmed, lose initiative and motivation in everything they do, and become lazy in life. Some patients feel helpless, and many of them are reluctant to seek medical help, feeling that everything is irreversible and no one can save them. Some patients feel that their days are like years, they are extremely lonely, and they have a sense of alienation from people around them.
4. Psychomotor retardation or agitation
About half of the patients have psychomotor retardation, which is one of the typical symptoms of depression. The whole mental activity shows significant and generalized inhibition. Thinking is closed, association is difficult, reaction is slow, memory and attention are diminished. Activity and speech are reduced, voice is low, replies are simple, walking and moving slowly, bedridden or living alone in one place. In severe cases, no speech, no food, no movement, and may reach a state of xerostasis.
In contrast, the agitated patient’s brain repeatedly thinks about something without a purpose, the content of the thought is unstructured, and the brain is constantly under tension. However, because of the inability to focus on a central problem, the efficiency of thinking is reduced, and creative thinking is not possible. In terms of behavior, the patient is irritable, nervous and agitated, sometimes unable to control his movements, but does not know why he is irritable.
5. Appetite, weight and sleep symptoms
Most patients have decreased appetite, resulting in weight loss, while a few patients have increased appetite; early awakening is a typical symptom, which can be manifested as difficulty in falling asleep, poor sleep and easy awakening.
6.Suicidal idea and behavior
Suicide is the most serious and dangerous symptom of depression patients, and is also the main cause of death in depression patients. According to statistics, the suicide rate of depression is about 20 times higher than that of the general population. Suicide due to depression accounts for about 80% of all suicides, and suicidal ideation can occur in the early and developmental stages of the disease, so vigilance should be raised. With the aggravation of symptoms, suicidal thoughts become increasingly strong, feeling that life is a burden, life is not worth staying, and try every possible way to end this life, to find relief.
7. Self-blame and self-guilt
The patient blames himself for some minor faults or mistakes in the past, thinks that some of his actions have made others feel disappointed, and his illness has brought a huge burden to his family and society. In severe cases, the patient may be delusional about his or her own faults.
8.Other symptoms
Depressive disorder can also have a variety of other symptoms, including a variety of physical complaints, common complaints include headache, neck pain, low back pain, muscle cramps, chest tightness, rapid heartbeat, frequent urination, sweating, nausea, vomiting, swelling of the throat, dry mouth, constipation, burning sensation in the stomach, indigestion, flatulence, blurred vision, and painful urination, etc. Patients with these symptoms often go to the general hospital repeatedly, so that Patients with these symptoms often go to general hospitals repeatedly, so that they cannot be diagnosed in time.
II. Clinical types
1.Depression
Major depressive disorder (MDD) can have all of the above symptoms, and the degree of seriousness, hallucinations and delusions, with delusions more common, also known as delusional depression or psychotic depression. Rarely, it is a mute depression, such as psychomotor depression, which can reach silence and inactivity. The duration of each episode varies from person to person, with a natural course of about six months, and in a few cases up to 1 to 2 years. The symptoms of depressive disorder are more typical and severe than those of dysphoria, but the remission is often more adequate.
2.Hypochondriacal state, also known as depressive neurosis
It is a mild depressive disorder with some or all of the above symptoms. Patients have an early age of onset, mostly in adolescence or early adulthood insidious onset, the clinical depressive symptoms are relatively mild or less typical, often accompanied by anxiety, somatic unsuitable for sleep disorders, no obvious psychomotor depression or psychotic symptoms, patients have treatment requirements, the degree of impact on life is less than depression, and the course of the disease is prolonged, will continue for several years without healing.
III. Diagnosis and differential diagnosis
1.Diagnostic points
(1) Diagnostic points of Western medicine
Diagnostic criteria for depressive disorders in the third edition of the Chinese Classification of Mental Disorders and Diagnostic Criteria
2.Diagnostic criteria for depressive episode
(1) Symptomatological criteria: mainly depressed mood with at least 4 of the following.
(1) Loss of interest, no sense of pleasure;
②Loss of energy or fatigue;
(3) Psychomotor retardation or agitation;
④ low self-esteem, self-blame, or feelings of guilt;
⑤ Difficulty in association or reduced ability to think consciously;
(6) Recurrent thoughts of death or suicidal or self-injurious behavior;
(7) Sleep disorders, such as insomnia, early awakening, or excessive sleep;
(8) Decreased appetite or significant weight loss;
⑨ Decreased sexual desire.
(2) Severe criteria: impaired social function, causing pain or adverse consequences to the person.
(3) Disease duration criteria.
(1) Meet the symptom criteria and severity criteria has lasted at least 2 weeks;
(2) Some schizophrenic symptoms may exist but do not meet the diagnosis of schizophrenia. If the symptom criteria of schizophrenia are also met, the depressive episode criteria are met for at least 2 weeks after the remission of the schizophrenic symptoms.
(4) Exclusion criteria: exclude organic mental disorders, or psychoactive and non-addictive substances caused by.
3.Diagnostic criteria of bad mood
(1) Symptomatological features.
(1) Symptomatological features: ① Decreased interest, but not lost.
(2) Pessimistic and disappointed about the future, but not despair.
(3) Decreased self-evaluation, but willing to accept encouragement and praise.
④Reluctant to actively interact with people, but good passive contact and willing to receive sympathy and support.
⑤ Have thoughts of death, but are apprehensive.
⑥Self-perceived serious and difficult to treat, but actively seeking treatment and hoping to be cured.
(2) Generally without the following symptoms.
(1) Obvious psychomotor depression.
(2) Early awakening and morning heavy symptoms and evening light.
(3) Severe guilt or self-blame.
(4) Persistent loss of appetite and significant weight loss.
⑤More than one attempted suicide.
(6) Inability to take care of oneself; hallucinations or delusions.
(7) Self-awareness deficit.
(3) The following criteria must be met for the diagnosis of a severe state of mind.
(①Symptomatological criteria: persistent depressed mood that does not meet the symptom criteria of any one type of depression, as well as the absence of manic symptoms.
(2) Severity criteria: less impaired social function and complete or more complete self-knowledge.
(3) Disease duration criteria: meeting the symptom criteria and severity criteria for at least 2 years, and in these 2 years, there is rarely an interval of normal mood lasting 2 months.
(4) Exclusion criteria.
(①Mood changes are not a direct consequence of somatic illness, or psychoactive substances, nor are they additional symptoms of schizophrenia and other psychotic disorders.
(2) Exclude all types of depression, once the corresponding criteria for other types of affective disorders are met, the corresponding diagnosis of other types should be made.
③Exclude depressive personality disorder.
4. Key points of TCM diagnosis
(1) Diagnosis of disease location: first of all, identify the internal organs affected by the disease, Chinese medicine believes that depression occurs mainly because the liver is not draining, the spleen is not healthy, and the heart is not nourished, according to clinical symptoms, identify the differences in the focus of the internal organs affected by the disease. Generally speaking, the main lesion of qi stagnation is in the liver, the main lesion of phlegm coagulation is in the spleen, and the deficiency is closely related to the heart and kidney.
(2) Diagnosis of pathology: The symptoms of deficiency should be distinguished from the real ones. Qi stagnation, blood stasis and phlegm coagulation are real, while the symptoms caused by deficiency of qi and blood or yin and essence of heart, spleen and liver are mostly deficiency.
(3) Differentiation of symptoms: defining depression and dirty agitation; depression is caused by emotional discomfort and qi stagnation, with depression, emotional restlessness, chest fullness, distension and pain in the ribs, or easy crying and anger, or foreign body obstruction in the throat as the main clinical manifestations of a class of diseases. Dirty mania is a kind of depressive disease, which mostly occurs in young and middle-aged women and is often triggered by mental stimulation, manifesting mental trance, restlessness, sadness and crying, and lack of stretching at times.
II. Differential diagnosis
1. Neurosis
It is mainly distinguished from neurasthenia. Bad mood (depressive neurosis) often presents with insomnia, headache, weakness, dizziness, etc., and is easily diagnosed as neurasthenia. There is no significant difference between the prevalence of neurosis and the group prevalence among the first-degree relatives of neurasthenia patients, while depression has significant family aggregation; depressive neurosis is eager to seek treatment, has thoughts of death but has many concerns, is pessimistic and disappointed but not desperate, is willing to accept encouragement from others, and has no suicidal behavior. Depressive neurosis and depression belong to the same disease family, which has been separated from neurosis and classified as depressive disorder.
2.Psychogenic depression
The onset of the disease is closely related to psychological factors and symptoms, clinical symptoms mainly reflect the content related to psychological factors, mood volatility, easily influenced by the outside world, psychomotor depression is not obvious. Insomnia is mostly characterized by difficulty in falling asleep, no early awakening, heavy daytime and light nighttime. Emotions are mostly resentful and rarely blame themselves.
3.Anxiety disorder
A significant proportion of patients with depression or bad mood are accompanied by anxiety symptoms in their clinical presentation, and sometimes it is difficult to distinguish them from anxiety disorders. Generally speaking, patients with depression and anxiety disorders can both show various symptoms of autonomic dysfunction, such as palpitations, insomnia, and worry, but patients with anxiety disorders may show more increased functional activity of the sympathetic nervous system, while patients with depression or bad mood may have more self-evaluation or negative perceptions.
4.Schizophrenia
Schizophrenia can have depressive symptoms in any of the disease phases. If, during the disease episode, schizophrenia has its core symptoms, such as hallucinations and delusions due to thought disorders and cognitive dysfunction, it is not difficult to identify; if depressive symptoms appear during the recovery period of schizophrenia, they can be identified based on the typical history of schizophrenia.
The schizophrenic catatonic type is similar to the depressive malaise symptoms of depression, but the former patient is clearly conscious, can recall the situation after the symptoms disappear, can be slightly active or self-eating in the dead of night, mental activity is not coordinated with the environment, often accompanied by stereotypes, defiance, and nervous excitement; the latter’s emotional activity is compatible with his inner experience whether in terms of expression, posture, and symptoms are often heavy day and light night.
5.Depressive disorder caused by drugs and physical diseases
Certain anti-hypertensive drugs, antipsychotic drugs and somatic diseases such as influenza, Parkinson’s disease, Addison’s disease, Silhan’s disease, cerebral arteriosclerosis, brain tumors, etc. can cause depressive symptoms, which are secondary depressive disorders. The differential diagnosis of functional depressive disorder depends on detailed medical history, clinical manifestations, physical examination and the necessary auxiliary examinations.
6.Dementia
Some patients with dementia have obvious early depressive symptoms, which can be easily confused with geriatric depression. Generally speaking, dementia is insidious in onset, slow in progress but progressive in symptoms, usually superficial in emotion, subjective distress and guilt are not obvious, and there are often positive findings in neurological system, EEG and neuroimaging. In depression, although the onset is slow, the time of onset is clearer and the disease progresses faster, often reaching its peak within 1 or 2 weeks, with episodes of symptoms and intervals of complete return to normal, with more prominent emotional distress and anxiety.
III. Treatment
Treatment strives to be systematic and adequate in order to obtain stable efficacy. The goal of treatment is to improve the clinical efficiency and cure rate, and to minimize the disability and suicide rate. The key to success is to completely eliminate clinical symptoms and reduce the risk of relapse. The second is to improve the quality of survival, restore social function, and prevent recurrence as the ultimate goal of treatment.
The dose of general therapeutic drugs is gradually increased, and the smallest effective amount is taken as much as possible to minimize adverse effects. In the acute stage, treatment is based on antidepressant drugs and/or Chinese herbal medicine and acupuncture, together with psychotherapy. For mild to moderate depressive disorders, a single herbal medicine, acupuncture and other Chinese medicine treatment can be considered, together with psychotherapy. The consolidation period treatment is at least 4 to 6 months.
The main purpose of maintenance period treatment is to prevent relapse, which generally tends to be 3 to 5 years, and long-term maintenance treatment is advocated for those with multiple recurrent relapses. Psychotherapy and TCM treatment methods are advantageous for consolidating the efficacy and preventing relapse. For those who cannot tolerate western medicine, or have somatic diseases, or western medicine treatment is not effective, combining with TCM can reduce side effects, improve treatment compliance and increase the efficacy. For some patients with depression, or mild or moderate depressive disorders, a single TCM treatment method can be used to treat them.
TCM treatment should be based on the principle of combining disease identification with evidence identification. The basic principle of treating depression is to regulate qi and open up depression, to regulate qi flow, and to enjoy the emotions and sex. For actual symptoms, the first treatment should be to regulate qi and open depression; and according to whether there is also blood stasis, phlegm knot, fire, etc., the treatment methods should be used to activate blood, lower fire and dispel phlegm. In case of deficiency, treatment should be administered according to the different conditions of the damaged internal organs and deficiency of qi, blood, yin and essence, either to nourish the heart and calm the mind, or to nourish the heart and spleen, or to nourish the liver and kidney.
For those with mixed deficiency and actuality, the deficiency and actuality should be taken into account depending on the preference of deficiency and actuality. The duration of the disease is usually long, so the medication should not be too fierce. In the treatment of actual disease, attention should be paid to regulating Qi without depleting Qi, invigorating Blood without breaking Blood, clearing heat without defeating the stomach, and dispelling phlegm without injuring the right; in the treatment of deficiency, attention should be paid to nourishing the heart and spleen without drying, and nourishing the liver and kidney without becoming greasy.
IV. Western medical treatment
1.Medication
Antidepressants are the main drugs for treating various depression disorders, which can effectively relieve depression and accompanying anxiety, tension and somatic symptoms, with an efficiency of about 60%~80%, and can also be combined with anxiolytics, mood stabilizers, thyroid preparations and antipsychotics according to clinical needs.
(1) Tricyclic (TCAs) antidepressants
Commonly used drugs: promethazine, amitriptyline, clomipramine, doxorubicin, and maprotiline belong to the tetracyclic class, but the pharmacological properties are similar to those of TCAs. The main pharmacological effect is to inhibit the reuptake of monoamine neurotransmitters in the presynaptic membrane to increase the content of monoamine transmitters in the synaptic gap and exert antidepressant effects. It is indicated for various types and severity of depressive disorders. TCAs are contraindicated in patients with severe heart, liver and kidney disease, pregnant women and the elderly.
(2) Selective 5-HT reuptake inhibitors (SSRIs)
Commonly used drugs: fluoxetine, paroxetine, sertraline, fluvoxamine, citalopram (or escitalopram), which exert antidepressant effects by selectively inhibiting 5-HT reuptake and increasing 5-HT content in the synaptic gap. The side effects of SSRIs are lighter and safer than tricyclics.
2.Other antidepressants
5-HT and NE reuptake inhibitors (SNRIs), through the simultaneous increase of 5-HT- and NE-energy neurotransmission play an antidepressant effect, the representative drugs are Wanlafaxin, Duloxetine, Reboxetine, the drug often has gastrointestinal reactions, for hypertensive patients, use with caution. The main mechanism of action is to enhance the transmission of NE and 5-HT energy and specifically block 5-HT2 and 5-HT3 receptors to play an antidepressant role.
Representative drugs include mirtazapine, which improves sleep for those who have difficulty falling asleep, with the side effect of dizziness, and NE and DA reuptake inhibitors (NDRIs), which mainly increase NE neurotransmission and play an antidepressant role. The representative drug, bupropion, has mild side effects and is relatively safe for the elderly, frail and those with cardiac and cerebral diseases. There is another one: agomelatine, which is both the first melatonin receptor agonist and 5-hydroxytryptamine 2C (S-HTx) receptor antagonist.
Animal tests and clinical studies have shown that this drug has antidepressant, anxiolytic, sleep rhythm adjustment and biological clock regulation effects, while it has few adverse effects, no adverse effects on sexual function, and no withdrawal reactions have been observed. Monoamine oxidase inhibitors (MAOIs), although the efficacy, but there are many harmful effects, few people are now using.
3.Electroconvulsive therapy
This therapy is suitable for some special cases of affective disorders, to lift the patient refusal to eat, serious suicide attempts, depression and rigidity have unexpected effects, often in 1 to 2 electroconvulsive therapy can be significantly improved, and is conducive to the continued implementation of psychotropic drugs and psychotherapy. In addition, it is effective for depression with poor antidepressant efficacy and depression with psychotic symptoms, and can block recurrent episodes of biphasic rapid cycling type. The current electroconvulsive therapy is a modified non-convulsive electroconvulsive therapy.
4.Psychotherapy
Psychotherapy can reduce and alleviate depressive symptoms of psychosocial stressors, improve patients’ compliance with medication, correct various adverse psychosocial consequences secondary to depressive disorders, and maximize patients’ recovery of psychosocial and occupational functions. It can also be used in conjunction with antidepressant maintenance therapy to prevent relapse of depression.
Supportive psychotherapy can be applied to all patients, and can be used or combined with all types of depression; psychodynamic short-course psychotherapy can be used to treat certain subtypes of depressive disorders, with selected adaptation; cognitive-behavioral psychotherapy can correct patients’ cognitive biases, reduce affective symptoms, improve behavioral coping skills, and reduce relapse in patients with depressive disorders; interpersonal psychotherapy mainly deals with Interpersonal psychotherapy mainly deals with the interpersonal problems of patients with depressive disorders and improves their social adjustment ability; Marital or family therapy can improve the couple relationship and family relationship of patients with depressive disorders in recovery and reduce the influence of poor family environment on disease relapse.
Music has a de-escalating effect on emotions, and can vent aggression, depression, restlessness and other emotions; choose music suitable for the patient’s psychological (especially emotional aspects) and condition, and develop a series of applicable music prescriptions, which can be adjusted according to the patient’s response at any time during the treatment process to achieve better results.