What depression feels like, All you should know
Things you will learn about
There are so many conditions in which a person becomes sad and not feel good. But today on google there are so many searches about what depression feels like?
So many people daily suffer from mental stress due to various reasons. There can be so many reasons which cause mental stress, such as
Mental trauma due to some bad experiences,
- Financial crises,
- Disappointed love,
- Loss of job and so many others.
In this article, we will discuss what depression feels like. Also, we will discuss other things related to depression as well as mental health, and many more such as:
- What is depression?
- Is depression a mental illness?
- Is depression genetic?
- Is depression curable?
These are the common terms that are mostly searched by so many people throughout the world. So today we will discuss briefly what depression feels like.
What is depression?
Hippocrates used the term melancholia for depression. The term depression word derived from the Latin word “deprive mere” which means to “press down”.
There are different opinions about depression by different people around the world which are as follows.
Emil Kraepelin: ‘ Depressive states’ as a part of ‘ Maniac-depressive Psychosis’
Henry Maudsley : ‘ Endogenous (melancholic) and ‘reactive’ (neurotic) types
DSM-I
DSM-II: Depressive neurosis
DSM-III onwards: Major depressive disorder
ICD-10: Depressive episode/recurrent depressive disorder.
Aretaeus of Cappadocia, a physician in ancient Greece wrote about a group of patient’ laugh, play, dance night and day, and sometimes go openly to the market crowned, as if vectors in some contest of skill’ only to be ‘torpid, dull, and sorrow full’ at the other times.
Chinese and Persian physician independently described this disorder:
- Jules Bailarger: folie a double forme (‘dual-form insanity)
- falret called it folie circularie (‘circular insanity’)
Emil Kreapelin distinguished ‘ Manic-depressive psychosis from ‘Dementia praeox’ (now called schizophrenia)
The term ‘Bipolar disorder’ was introduced formally in DSM-III
Mood disorders are also called ‘Affective’ disorders. There are mainly two types of mood disorder;
- Depression
- Bipolar disorder
In this article, we will discuss depression and what depression feels like. Also, we will discuss other related things with depression, make sure to read this article till the end.
In depression, the patient experience one or more episodes of low mood. Also called ‘Unipolar’ Disorder.
Depression is a common and serious medical condition or illness that negatively affects how you feel, the way you think and how you acts.
Depression causes a feeling of sadness and or loss of interest in an activity once you enjoyed. It can lead to a variety of emotional and physical problems and can decrease a person’s ability to function at work and at home.
Clinical features of depression
- Depressed mood that is clearly abnormal for the person
- Anhedonia (Inability to drive pleasure from normally pleasurable activities)
- Decreased energy / Increased fatiguability
- Sleep disturbance (usually early morning awakening)
- Appetite disturbance (usually decreased + weight loss)
- Diurnal mood variation (usually worse in the morning)
- Reduced concentration
- Psychomotor agitation / retardation
- Feeling hopeless/ helpless / worthless
- Suicidal ideas/ plan / acts
Psychotic symptoms in depression
Both delusion and hallucinations can occur. There can be two types of symptoms which you can observe in opposite person which are as follows:
- Delusions of:
- Guilt
- Worthlessness
- Hypochondriasis
- Nihilism (body rotting, world-ending soon, etc.)
- Voices accusing or condemning the patient
- Delusions of reference or persecution
- The voice speaking about affectively neutral topics
Depression in bipolar disorder
Depression occurring in bipolar disorder is generally clinically indistinguishable from unipolar depression. So, in any first episode of depression, the possibility of bipolar needs to be borne in mind.
A patient with significant depression may not be able to recall any happy memories (including hypomania/maniac). So, always useful to get information from a family member/friend who has known the patient for many years.
40% of patients with bipolar disorder are initially diagnosed with unipolar depression. Some features that may suggest bipolar depression are as follows:
- Atypical features ( increased sleep, increased appetite)
- Psychomotor retardation
- More frequent episodes
- Family history of bipolar disorder
- Lower age of onset
- Male gender (equal gender prevalence for bipolar)
- More abrupt onset.
Depression in ICD- 10
F32 Depressive episode is as follows:
F32.1 Moderate
F32.2 Severe-without psychotic symptoms
F32.3 Severe-with psychotic symptoms
- .30 Mood-congruent psychotic symptoms
- .31 Mood-incongruent psychotic symptoms
F33 Recurrent depressive disorder.
This diagnosis is used for those with 2 or more episodes of depression. The previous diagnosis (Depressive episodes) is used for the first episode of depression.
In recurrent depressive disorder, rate the current episode as mild, moderate or severe as above, or whether the patient is currently in remission.
Endogenous vs Reactive Depression.
- Endogenous depression.
- Reactive depression.
These subtypes are no longer included in ICD or DSM
1. Endogenous depression
Depression occurring spontaneously without any external stressor. Also called ‘Melancholic’ biological / ‘Psychotic’ Depression. It is characterised by
- Prominent biological/somatic symptoms of depression.
- More severe symptoms(e.g. Psychomotor retardation) / psychotic symptoms
- May respond better to TCAa than SSRIs
- More likely to need Antipsychotics /ECT.
2. Reactive depression
Depression occurring in response to a clearly identified external stressor (e.g. Bereavement). It is also called ‘Neurotic’ depression. Characterised by
- Less severe
- More effective symptoms (e.g. Irritability, anxiety, guilt, etc.)
- Significant overlap with ‘Adjustment disorder’
- Spontaneous recovery is more common.
Atypical Depression
In ‘Typical depression’: there is reduced sleep, reduced appetite and weight loss.
Whereas in ‘Atypical depression: there is hypersomnia ( increased sleep ), increased appetite and weight gain. Other features of Atypical depression are as follows;
- Feeling of heaviness in arms and legs ( ‘Leaden paralysis’ )
- Excessive sensitivity to interpersonal problems ( ‘Interpersonal rejection sensitivity)
- Bipolar depression tends to have more Atypical features than Unipolar depression
- The seasonal affective disorder is characterised by Atypical features
- Atypical depression may be responded better to MAOIs than TCA or SSRIs.
Epidemiology of Unipolar depression
- Lifetime prevalence is about 15 %.
- Annual incidence is about 5%
- About twice as common in women as men
- The average age of onset: about 30 years
- The peak age group of onset;
- 30 to 44 years
- 18 to 29 years
Epidemiology of Bipolar depression
- Lifetime prevalence is about 1% for Bipolar I
- The lifetime prevalence of bipolar spectrum disorder ( including types I, II, cyclothymia, etc.) may be above 5 %.
- Similar prevalence of Bipolar I in males and females
- Bipolar II and Rapid-cycling subtypes more common in females.
- The average age of onset: 25 years
- The peak age group of onset: 20 to 40 years
- About 20% have onset before 20 years.
- About 10% have onset after 60 years.
- The first episode is depression more common in females.
- The first episode is mania common in men.
Aetiology of depression in genetics
First degree relatives have 3-fold increased risk factors of depression. Genetics is less important for late-onset depression.
Two susceptibility loci MDD1 and MDD2 (on chromosomes 12 and 15 respectively) have been identified. Other potential genes: TPH2, HTR3A, HTR3B genes.
Polymorphism of the serotonin transporter (SLC6A4) gene (on chromosome 17) -5HTTLP; short allele homozygosity or heterozygosity associated with increased risk of depression, in response to stressful life events, then long allele homozygosity.
Genetic factors may also mediate drug response or side-effects
Aetiology of depression- Psychosocial
- Recent stressful life events (especially a loss-e.g. bereavement)
- Loss of parent before age 10
- Living alone / lack of social support
- Chronic pain
- Alcohol and substance misuse
- Medication: steroids, anti-hypertensive. etc.
- Vascular: stroke & CAD increase the risk of depression and vice versa.
Assessment
Perform a thorough Psychiatric assessment and take a comprehensive medical history. It is important to do a proper risk assessment:
Patients with Depression (both unipolar and bipolar) and mixed states of Bipolar disorder try to shorten their life more in comparison to normal people.
Patients with severe mania may place themselves or they’re at risk by their reckless behaviours (e.g. Running on the road unmindful of traffic)
About 5 to 10 % of the patient with untreated / inadequately treated Unipolar depression try to shorten their lives.
About 10 to 15 % of patient with Bipolar disorder try to shorten their lives.
Co-Morbidity
Co-morbidity is common for both unipolar and bipolar disorders. Common co-morbid psychiatric disorders include;
- Anxiety disorder
- Substance misuse
- Personality disorders
- Eating disorders
- ADHD
Physical co-morbidity include;
- Thyroid dysfunction ( in addition to that included by Lithium)
- Migraine
- Metabolic syndrome ( in addition to that induced by Antipsychotics)
Investigation
Unless specifically indicated, no need for :
- Neuroimaging like CT or MRI
- EEG
- Psychometric testing / Neuropsychological testing / Structured personality questionnaires.
- Do routine blood tests before initiating treatment (CNC, LFT, U&E, TFT, Glucose, Lipids, etc.)
- Hypothyroidism can mimic symptoms of depression
- Baseline ECG.
Rating Scales
Several rating scales are available to rate the severity of depression and some for mania also. It is mainly used in clinical studies not needed routinely in clinical practices.
Some rating scales used in Depression :
- BDI (Back Depression Inventory)
- HAM-D (Hamilton Rating Scale for Depression)
The most commonly used rating scale for mania is YMRS ( Young Mania Rating Scale)
BDI ( Back Depression Inventory )
- Self-rating scale
- 21 items, each rated on a scale of 0 to 3
- Lowest possible overall score :0
- Highest possible overall score :3
One suggested scoring:
- Up to 10: borderline depression
- 11 to 16: mild depression
- 21 to 30: moderate depression
- 31 to 40: severe depression
- Above 40: extreme depression
Treatment for Depression
There are two main treatments available for depression, used either on their own or in combination:
- Anti-depressants
- Psychotherapy (usually CBT – Cognitive Behaviour Therapy)
Rationale for Anti-depressants
Monoamine Hypothesis of Depression: This states that depression is due to a deficiency of monoamines ( Serotonin or Nor adrenalin or both) in the brain.
So, by increasing the levels of one or both of these monoamines, depression can be treated.
Classification of Antidepressant
1. older or first-generation
- Tricyclic Antidepressant (TCAs)
- Monoamine Oxidase Inhibitors (MAOIs)
2. New or Second generation
- Selective Serotonin Reuptake inhibitors (SSRIs)
- Serotonin Noradrenalin Reuptake Inhibitors (SNRIs)
- Noradrenaline and Specific Serotonin Anti-depressants (NaSSA)
- Noradrenaline Reuptake Inhibitor (NARI)
- Noradrenaline Dopamine Reuptake Inhibitor (NDRI)
Discontinuation Syndrome with Anti-depressant
This is an increasingly recognised phenomenon. It tends to be more severe the shorter the half-life of the antidepressant.
Symptoms include insomnia, nausea, anxiety, dizziness, paraesthesia, mood changes and diarrhoea. We can reduce the risk of this syndrome by gradual reduction of dose rather than abrupt cessation.
Common with antidepressants with relativity short half-lives (e.d. Venlafaxine, Paroxetine), and usually with antidepressants with a long half-life(e.g. Fluoxetine)
Serotonin syndrome
It can occur during co-administration of SSRIs with other drugs that also increase 5HT availability ( other antidepressants like MAQIs).
- Features may be similar to NMS:
- Hyperpyrexia
- Nausea, Vomiting
- Diarrhoea
- Sweating
- Automatic instability
- Clouding of consciousness
Treatment Includes:
- Supportive (IV fluids, anti-pyretic, etc.)
- Benzodiazepines (for agitation, to prevent seizures)
- Cyproheptadine (serotonin receptor antagonist)
General principal when using antidepressants
‘Start low, Go slow’:
- Start at a low dose.
- If needed, increase the dose gradually
- Review mental state regularly
- Monitor for side-effects
- Avoid ‘poly-pharmacy (using more than one antidepressant, except for treatment-resistant depression)
- It usually takes at least 2 to 3 weeks for the anti-depressant effect to manifest.
- If the patient improves, continue medication for several months after recovery.
- If stable, withdraw gradually to avoid ‘rebound’ relapse.
- If the patient does not improve, gradually change to another antidepressant.
- If repeated relapses, consider long-term (possibly life-long) maintain treatment.
Cognitive Behaviour Therapy
The rationale for using CBT Depression
How one thinks (cognition) and how one acts (behaviour) can affect how one feels (mood). Negative cognitions and maladaptive behaviours can cause one to feel low in mood.
The aim of CBT is to help the patient correct negative cognitions and unhelpful behaviours that maintain the depression, by using cognitive and behavioural strategies.
Indication for electroconvulsive therapy (ECT) in depression
- Severe, life-threatening depression: patient not eating or drinking
- Depressive stupor
- Severe, psychotic depression (e.g. Post-partum psychosis)
- Treatment-resistant depression: when different anti-depressant and CBT have been unsuccessful
Treatment-Resistant Depression
Refers to depression that has not responded to at least 2 different classes of antidepressants gives at an adequate dosage for an adequate duration ( at least for 4 to 6 weeks)
Assess :
- Compliance
- Alcohol or drug misuse
- Interaction with other medication (e.g. Enzyme inducers)
- Role of physical illness (e.g. poorly controlled pain)
- Psychological / Social stressors.
Strategies for treatment-resistant depression
Common: (Done routine in Psychiatric Outpatients clinics)
1.Combination strategies : combining 2 antidepressant treatments:
- Antidepressant 1 (e.g. Velanfaxine) + Antidepressant 2 (e.g. Mirtazapine)
- Antidepressant + CBT for Depression
- Antidepressant +
- Lithium (or)
- T3(or)
- Atypical antipsychotic
Uncommon: (mainly in psychiatric Inpatient Units, especially for Geriatric Depression)
- 1. ECT
Rare : ( via specialist Mood disorder / Neurology centres)
- Repetitive Transcranial Magnetic Stimulation (rTMS)
- Transcranial Direct Current Stimulation (tDCS)
- Deep Brain Stimulation (DBS)
- Vagus Nerve Stimulation (VNS)
Very, very rare: (only in a handful of Neurosurgery centres around the world; usage continues to further decline)
- Psychosurgery (Neurosurgery for Mental disorder)
Mood Stabilizers
- Lithium
- Divalproex Sodium (valproate semi sodium) / Valproate Sodium
- Carbamazepine
- Lamotrigine
Conclusion
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