Depression

Depression is a mental illness that begins with subtle signs such as difficulty focusing, poor recall abilities, persistent low mood, and changes in appetite. Many people tend to ignore these signs until they manifest as a clinical illness, which can have serious and life-changing health implications. Here are the most common and early signs of depression. If you or anyone in your family is experiencing these signs, consulting a therapist or psychiatrist may be necessary.

1. Getting irritated very often
   Many people think that depression leads to just sadness. However, some individuals with depression may experience frequent anger and irritability over trivial issues. While these signs could also be due to stress, increased irritability should not be ignored. Consider the possibility of depression if you notice these changes in behavior.
2. Loss of interest
   A common sign of depression is a lack of interest in previously enjoyable activities such as hobbies, socializing, and intimacy. Individuals may avoid social gatherings, become more withdrawn, and lose motivation for daily goals.
3. Changes in appetite
   A dramatic change in appetite is a classical sign of depression, which may manifest as eating too much or too little. A weight gain or loss of more than 5% of body weight in one month could indicate depression. Some people may eat to cope with their feelings, while others may lose interest in food altogether.
4. Being too pessimistic
   If you find yourself consistently criticizing and holding negative opinions about everything, it could be a sign of depression.
5. Sleep disturbances
   Many individuals with depression first consult their doctor due to sleep disturbances. While occasional sleep issues are normal, persistent difficulties or insomnia can be symptomatic of depression. Some may struggle to fall asleep or stay asleep, while others may sleep excessively.
6. Having aches and pains
   Mental health issues can manifest as physical symptoms. Many people with depression experience unexplained body aches, muscle pains, and headaches, often attributing these to physical health problems and taking painkillers instead.
7. Feeling tired all the time
   Depression can lead to chronic fatigue and low energy levels. Many attribute this to workload or aging, neglecting to address it timely. If small tasks exhaust you or take longer to complete, it may indicate depression.
8. Feeling of guilt
   Excessively blaming yourself for events in your life is unhealthy. If you hold yourself responsible for personal, professional, and childhood issues, it may be a sign of depression. Many individuals with depression also feel worthless. Pay close attention to your inner thought process; excessive harshness or criticism could indicate depression.
9. Difficulty in concentration
   Individuals with depression often experience forgetfulness and misplace items frequently. They may struggle to concentrate when giving or receiving directions, comprehending reading material, or remembering specific details.

Additional signs include:

• Low mood/sadness
• Crying spells
• Diminished interest in play and activities
• Problems with concentration
• Excessive tiredness/fatigue/weakness
• Behavioral symptoms such as anger and agitation
• Self-accusation/self-criticism
• Work difficulty
• Expectation of punishment
• Decreased appetite
• Anorexia
• Decreased sleep/change in sleeping pattern
• Increased appetite, weight gain, and excessive sleep
• Past failure/sense of failure
• Anhedonia (inability to feel pleasure in normally pleasurable activities)
• Anxiety symptoms
• Irritability
• Hopelessness
• Physical symptoms/multiple complaints such as headache, abdominal pain, and chest pain
• Suicidal ideations/thoughts
• Psychotic features in the form of persecutory delusions
• Catatonia (inability to move normally or speak)
• Depersonalization
• Obsessive-compulsive symptoms
• Guilt
• Attempted suicide
• Recent deterioration in school performance
• Dissatisfaction
• Self-dislike
• Indecisiveness
• Social withdrawal
• Loss of libido
• Body image changes
• Poor interaction
• Decreased interest in school
• Low self-esteem
• Death wishes
• Worthlessness
• Loss of energy

Note: Depressive episodes can be categorized as mild, moderate, or severe depending on the number and severity of symptoms, as well as the impact on the individual's functioning. Common signs and symptoms of depression in children and teenagers are similar to those of adults.

The exact cause of depression is not yet known. Depression can occur spontaneously, without any obvious reason. Some experts think it could be due to an imbalance in brain chemicals, while others believe it could be due to a genetic defect. Additionally, a person’s environment and emotions play a crucial role in developing depression. Hence, depression can be defined in 'bio-psycho-social' terms, meaning that it is a complex disorder most likely triggered by overlapping biological, psychological, and environmental factors.

What happens in the brain?

Our brain is made up of millions of nerve cells, also known as neurons. These cells are responsible for relaying chemical signals back and forth from the brain to various parts of the body. The neurons interact with each other via chemical messengers known as neurotransmitters (commonly referred to as brain chemicals). These messages help the brain to generate thoughts, emotions, and sensations, which play a key role in brain function and mental wellbeing.

What happens during depression?

In depression, it is believed that there is an imbalance in brain chemicals. There is either too much or too little of these neurotransmitters, which affects the ability to think, feel, and emote. These neurotransmitters include dopamine, serotonin, and norepinephrine. Medications to manage depression often focus on altering the levels of these chemicals in the brain. In some individuals with depression, brain scans show a smaller hippocampus, which plays a major role in long-term memory. Exposure to stress and other risk factors can impair the growth of nerve cells in the hippocampus and trigger depression.

Anyone can suffer from depression, even a person who appears to live in relatively ideal circumstances. However, there are many potential factors that can trigger or influence depression:

1. Family history and genetics
Genetic makeup and heredity are thought to be significant factors that influence depression. Some types of depression run in families, especially bipolar disorder. While studies suggest that there is a strong genetic component that increases the risk of developing depression, other factors are usually needed to trigger the symptoms.

2. Psychological and social factors
- History of physical, emotional, or sexual abuse
- Social isolation or loneliness
- Low socioeconomic status
- Stressful life events like loss of a loved one, divorce, loss of a job, and financial issues
- Positive events like marriage, moving, graduation, or retirement can also cause depression as they alter daily routines and potentially trigger feelings.

3. Medical conditions
Physical health and certain medical conditions like ongoing or chronic physical pain or disease, sleep disorders, thyroid disorders, diabetes, liver disease, multiple sclerosis, Addison's disease, Parkinson’s disease, and cancer can cause symptoms of depression.

4. Inflammation
Inflammation caused by diseases or stress may lead to chemical changes in the brain that can trigger or worsen depression in certain individuals. It can also affect the response to drug therapy.

5. Traumatic brain injury (TBI)
TBIs or concussions resulting from injuries to the head, such as falls, accidents, and workplace or sports-related injuries, are thought to trigger depression.

6. Certain medications
Some medications that treat hypertension (high blood pressure), cancer, and seizures can cause depression. Additionally, some psychiatric medications, including certain sleeping aids and medications used to treat alcoholism and anxiety, can trigger depression.

7. Personality
Individuals who are easily overwhelmed, have trouble coping with stress or anxiety, have low self-esteem, or are generally pessimistic or self-critical are more prone to depression.

8. History of other mental health conditions
Anxiety disorders, eating disorders, post-traumatic stress disorder, substance use disorders, and learning disabilities are commonly associated with or can perpetuate depression.

9. Lifestyle factors
- Recreational drug and alcohol use can cause depression or exacerbate existing conditions.
- Working late and waking up late or spending less time outdoors can disrupt the circadian rhythm, potentially triggering depression. Reduced sunlight can also lead to decreased serotonin and melatonin levels, affecting mood and sleep.

10. Poor diet
A poor or imbalanced diet with deficiencies in vital vitamins and minerals is known to contribute to depression. Low levels of omega-3 fatty acids, vitamin D, and an imbalanced ratio of omega-6 to omega-3 fatty acids are associated with higher rates of depression. Additionally, high sugar intake is thought to trigger depressive symptoms.

Why are women at a higher risk than men?
According to the World Health Organization (WHO), the burden of depression is 50% higher for females than males. Depression is widely prevalent among women in India across all age groups. Psychosocial and social factors contributing to the increased vulnerability of women to depression include:
- Stress
- Victimization
- Sex-specific socialization
- Coping style
- Disadvantaged social status
- Perceived stigma of mental illness
- Domestic violence

Women are at the greatest risk for developing depressive disorders during their childbearing years, which may be attributed to hormonal changes associated with menstrual cycles, pregnancy, and childbirth. The following types of depression can occur in females:
1. Premenstrual dysphoric disorder: A severe form of premenstrual disorder affecting women in the days or weeks before menstruation.
2. Antenatal depression: Also known as prenatal or perinatal depression, affecting women during pregnancy and can lead to postpartum depression if not treated promptly.
3. Postpartum psychiatric disorders: These can be divided into three categories: postpartum blues, postpartum depression, and postpartum psychosis.

Postpartum blues:
Postpartum blues, or "baby blues," occur in many women shortly after delivery. The mother may feel overwhelmed and experience sudden mood swings, impatience, irritability, restlessness, loneliness, sadness, or cry without reason. Postpartum blues typically do not require treatment and may resolve within days to a week. Support from family in sharing childcare duties and connecting with other new mothers can be beneficial.

Postpartum depression:
Postpartum depression can begin soon after childbirth or as a continuation of antenatal depression and requires treatment. The global prevalence of postpartum depression is estimated at 100–150 per 1000 births. Symptoms often mirror those of postpartum blues but are more intense and can last for up to one year. Postpartum depression can predispose individuals to chronic or recurrent depression, affecting the mother-infant relationship and child development. Children of mothers with postpartum depression may face greater cognitive, behavioral, and interpersonal challenges compared to those of non-depressed mothers, making timely treatment crucial.

Postpartum psychosis:
Postpartum psychosis, with a global prevalence of 0.89 to 2.6 per 1000 births, is a severe disorder that begins after childbirth. New mothers with postpartum psychosis may experience agitation, anger, unusual behavior, hallucinations, delusions, insomnia, and, in rare cases, suicidal or homicidal thoughts. Immediate medical attention is required.

Young vs. old: Who is more depressed?
The average age of onset for depression worldwide ranges from 24 to 35 years. In India, the average age of onset is 31.9 years. There is a trend toward a younger age of onset, with 40% of depressed individuals experiencing their first episode before age 20, 50% between ages 20 and 50, and the remaining 10% after age 50.

Adolescent depression:
The age of onset for depression has been decreasing and is increasingly recognized in children and adolescents. Factors associated with depression in this age group include:
- Stress at school
- Lower academic performance
- Failure in examinations
- Family stress
- Change of residence
- Death of a family member
- Prolonged absence or death of a parent
- Serious illness
- End of a relationship

The diagnosis of depression is based on history and physical findings. No diagnostic laboratory tests are available to diagnose major depressive disorder.

1. Psychiatric Evaluation

A comprehensive evaluation is needed to diagnose emotional, behavioral, or developmental disorders. The evaluation may include:

• Description of behaviors (e.g., duration of changed behavior and conditions in which behaviors occur)
• Complete medical history, including overall physical health, list of any other illnesses or conditions, and any current ongoing treatments

DSM-5 Guidelines: These are the 9 symptoms listed in the DSM-5. Five must be present to make the diagnosis of major depressive disorder (one of the symptoms should be depressed mood or loss of interest or pleasure):

• Sleep disturbance
• Interest/pleasure reduction
• Guilt feelings or thoughts of worthlessness
• Energy changes/fatigue
• Concentration/attention impairment
• Appetite/weight changes
• Psychomotor disturbances
• Suicidal thoughts
• Depressed mood

2. Blood Tests

While no diagnostic laboratory tests are available to diagnose major depressive disorder, laboratory tests can help exclude underlying medical conditions that may manifest as depression. These include:

• Complete blood cell (CBC) count
• Thyroid-stimulating hormone (TSH)
• Vitamin B-12
• Rapid plasma reagin (RPR)
• Toxic screening (to rule out active substance abuse)
• HIV test
• Electrolytes, including calcium, phosphate, and magnesium levels
• Blood urea nitrogen (BUN) and creatinine
• Liver function tests (LFTs)
• Blood alcohol level
• Blood and urine toxicology screen
• Arterial blood gas (ABG)
• Dexamethasone suppression test (Cushing disease, but also positive in depression)
• Cosyntropin (ACTH) stimulation test (Addison disease)

3. Imaging Tests

Imaging tests can help rule out other medical causes and conditions. These include:

• CT scan
• MRI of the brain

Depression is among the most treatable of mental disorders. The treatment of depression involves both pharmacological (medical) and psychological approaches.

1. Medical therapy

The drugs used to treat depression are known as antidepressants. These drugs may produce some improvement within the first week or two of use; however, full benefits may not be seen for two to three months. If a patient feels little or no improvement after several weeks, their psychiatrist can alter the dose of the medication or add or substitute another antidepressant. In some situations, other psychotropic medications may be helpful. It is important to let your doctor know if a medication does not work or if you experience side effects. Possible reasons for no improvement in symptoms post-treatment include:

• Not taking the antidepressants for the recommended period, as ideally, they might take 8 to 12 weeks to show any effect.
• Not taking the medications regularly.
• Taking the medicines in low doses (under dosing).
• Always discuss with your doctor prior to making any dose changes.
• Concurrent substance abuse, which might contribute to the non-responsiveness of depressive symptoms.
• Some underlying medical disorder that has been unaddressed.

Antidepressants can be classified into typical antidepressants and atypical antidepressants.

A) Typical antidepressants

These are further divided into:

1. Selective serotonin reuptake inhibitors (SSRIs): SSRIs are used as frontline drugs for the treatment of depression and anxiety. These drugs increase the level of serotonin and brain-derived neurotrophic factor (BDNF). Examples of this class include:
• Escitalopram
• Fluoxetine
• Sertraline
• Paroxetine
2. Serotonin and noradrenaline reuptake inhibitors (SNRIs): SNRIs aid in the treatment of depression by increasing the levels of serotonin and noradrenaline in the body. Drugs in this category include:
• Duloxetine
• Milnacipran
• Venlafaxine
3. Monoamine oxidase (MAO) inhibitors: This type of antidepressant primarily increases the level of noradrenaline, thereby improving the symptoms of depression. Commonly prescribed MAO inhibitors include:
• Phenelzine
• Isocarboxazid
• Tranylcypromine
4. Tricyclic antidepressants (TCA): This class of antidepressants works by increasing levels of noradrenaline in the body. These are outdated medications. Examples include:
• Nortriptyline
• Amitriptyline
• Imipramine

Note: Selegiline, a newer MAOI that sticks on the skin as a patch, may cause fewer side effects than other MAOIs.

B) Atypical antidepressants: This class of drugs does not have a specific action mechanism. Common examples include:

• Mirtazapine
• Agomelatine
• Bupropion
• Atomoxetine

Here are 8 things about antidepressants everyone needs to know.

2. Psychotherapy

Also known as talk therapy or psychological therapy, this approach is commonly used for treating depression by discussing your condition and related issues in counseling sessions with a mental health professional.

Cognitive behavioral therapy (CBT): This type of psychological therapy helps teach the patient coping skills to manage their difficult conditions. The therapy focuses on the cognitive component, helping the patient change their thinking about a situation, and the behavioral component, which further helps them change their reactions to any situation.

Interpersonal therapy (IPT): This is a time-limited approach that focuses on improving the symptoms of depression and treating mood disorders. In this, a therapist engages the patient to improve their communication with others and solve problems.

3. Surgical and other interventions

Electro-convulsive therapy (ECT): Also known as shock therapy, this treatment is best for acute depression. It is useful for patients who do not respond to drug therapy, are psychotic, or are suicidal or dangerous to themselves. The onset of action may be more rapid than that of drug treatments, with benefits often seen within one week of commencing treatment.

Transcranial magnetic stimulation (TMS): This is usually reserved for those who haven't responded to antidepressants. During TMS, a treatment coil placed against the scalp sends brief magnetic pulses to stimulate nerve cells in the brain involved in mood regulation and depression.

Vagus nerve stimulation (VNS): This approach is also used in refractory cases. Like ECT, it uses electrical stimulation to relieve symptoms of depression. The difference is that the device is surgically implanted in the body. VNS is FDA-approved for the long-term treatment of chronic depression that does not respond to at least two antidepressant trials. Its effects may take up to nine months to appear, and studies have shown that a meaningful response occurs in about one in three people.

• Excess disability
• Forgetfulness
• Increased symptoms from medical illness
• Suicidal thoughts

Yoga

1. Setubandhasana (Bridge Pose)
   Lying flat on your back with your hands at your sides, bend your knees so that your feet are flat on the ground and as close to your buttocks as possible. Slowly raise your hips while keeping your hands at your sides and hold the pose for 5 breaths.
2. Marjariasana (Cat Stretch)
   Lying on the floor face down, rise onto all fours with palms planted on the ground and knees bent, resembling a cat. Your back should be gently arched. Breathe normally for 5 counts. This pose relaxes the stomach and spine muscles.
3. Sukhasana (Easy Pose)
   This pose promotes calmness in both mind and body. Sit cross-legged in a comfortable position with your spine straight and palms resting on your knees as if meditating. Breathe normally and focus on the breath entering and exiting your body.
4. Balasana (Child Pose)
   For this pose, sit on your heels with your knees bent. With your arms resting on your thighs, bend your torso towards the floor until your nose touches the ground. Bring your arms to your sides near your feet with palms facing upward. Breathe deeply for 5 to 10 counts.
5. Savasana (Corpse Pose)
   This pose is simple and leads to deep relaxation. Lie down on your back with your arms relaxed at your sides. Allow your body to relax and sink while taking deep breaths. You can also try a supported Savasana by placing a blanket or pillow along the length of your back.
6. Paschimottanasana (Seated Forward Bend)
   In addition to reducing depression and anxiety, this pose aids digestion, stretches the back and leg muscles, and promotes healthy kidneys and uterus. While sitting with your legs stretched out straight in front of you, bend your torso forward with your nose touching your knees. Reach your hands parallel and above your legs to hold your feet with your palms.

Here is a list of practical ways that will help you cope with depression effectively:

1. Speak up

To effectively fight depression, it is important for you to seek social help. Connect with your friends and family. Try to talk as much and share your problems. Talking about your worries will help to lessen the burden of your problem.

2. Engage in activities that make you happy

Depression wipes you off the energy and the zeal to engage yourself in activities that once were your passion. Not trying to pull yourself out of this state shall only worsen your depression. Engage yourself in activities that keep you happy to fight depression effectively. Stay active by opting for activities that relax and energize you.

3. Don’t be harsh on yourself

Depression puts you at an increased risk of self-hate and embarrassment. It makes you think negatively and very critically over all issues. It is important that you remain compassionate towards your own self and not demean or discourage yourself from connecting with others. Research suggests that supporting others has been found to boost one’s mood and makes one feel happy. To overcome this condition, it is important for you to love your own self.

4. Get moving

Depression tends to keep you in bed or glued to your couch. The less you move around the worse it may get. Go for a 20-minute walk every day with a friend or alone. You could also pick a sport that interests you or any other physical activity that would keep you moving. Exercise has been found to increase the production of neurochemicals such as endorphins that elevate the mood and make you happy.

5. Get some sunshine

Studies suggest that sunlight has a therapeutic effect on those suffering from depression. Sunlight has been found to boost depressed mood and serves as a therapy. Take short walks outdoors in the sunlight. Instead of opting to have coffee or tea in a dark room, try doing the same in the sun. If you practice yoga, do it during the early morning hours and enjoy the benefits of sunlight as well.

6. Have mood-enhancing foods

While fighting depression, include foods that are rich in B complex, Vitamin C, and omega-3 fatty acids. Omega-3 rich foods (rich in EPA and DHA) have been found to stabilize mood swings. Include foods such as fatty fish or fish oil supplements in your diet. Do not skip your meals. Make sure you eat at regular hours (2-3 hours). Minimize the intake of sugars and refined carbs such as bakery items, pasta, and french fries as they may lead to energy crashes.

7. Seek medical help

In severe cases, when all the above-mentioned practical tips fail to get results, it is better that you seek help from a therapist. Medical help will assist you in combating the situation and keeping your symptoms in check.

Depression and related conditions

Diabetes: Did you know the occurrence of depression is two to three times higher in people with diabetes mellitus? The prevalence rates of depression could be up to three times higher in patients with type 1 diabetes and twice as high in people with type 2 diabetes compared with the general population worldwide. The presence of depression and anxiety in diabetic patients is known to worsen the prognosis of diabetes, increase non-compliance to medical treatment, and lead to poor quality of life and mortality. The common causes could be stress and inflammation, as both promote depression and type 2 diabetes, creating a feasible common link between them.

Heart disease: Depression is known to be associated with poorer outcomes of coronary heart disease (CHD). It can act as a risk factor for a poor prognosis after a heart attack or unstable angina (chest pain at rest due to reduced blood flow to the heart). The risk of death in heart attack survivors with depression is three times that of those without depression. It has been linked to low-grade inflammation, which is involved in the clogging of arteries and the rupture of cholesterol-filled plaque. Depression also boosts the production of stress hormones, which dull the response of the heart and arteries to demands for increased blood flow. It activates blood cell fragments known as platelets, making them more likely to clump and form clots in the bloodstream.

Depression and other mental disorders

Anxiety disorders: Comorbid anxiety is common in patients with depressive disorders. It complicates the clinical presentation of depressive disorders and can contribute to treatment resistance. Studies have shown that more than 70% of individuals with depressive disorders also have anxiety symptoms, and 40 to 70% simultaneously meet criteria for at least one type of anxiety disorder. The concurrent presence of anxiety symptoms or anxiety disorders often complicates the treatment of depressive disorders.

Schizophrenia: Although technically, depression and schizophrenia are totally different, it is seen that depressed mood is commonly associated with first-episode schizophrenia. Schizophrenia is a chronic mental disorder that affects how a person thinks, feels, behaves, and interacts with his or her surroundings. Moreover, it is reported that these symptoms impair the everyday life of the patient as well as the quality of life, which requires medical treatment and, in some cases, hospitalization.

Eating disorders: Both depressive disorders and eating disorders are multidimensional and heterogeneous disorders. Research shows that 32-39% of people with anorexia nervosa, 36-50% of people with bulimia nervosa, and 33% of people with binge eating disorder are also diagnosed with major depressive disorder. They are much more common among women and girls, but men and boys account for about 5 to 15 percent of those with anorexia or bulimia and about 35 percent of those with binge eating disorder.

Substance abuse: There is a strong connection between substance use and mental illness. A strong link of depression with substance use and impairment suggests that depressed substance users may require enhanced treatment interventions.

Phobias: Phobias are a form of anxiety disorder, wherein a patient will have an irrational and all-encompassing fear of a person, place, thing, or a specific situation. Unfortunately, depression and anxiety are closely linked. Some common phobias include:

• Aviophobia/aerophobia (fear of flying)
• Emetophobia (fear of vomiting)
• Amaxophobia (fear of driving)