Byline: M. Reddy
With the backdrop, Depression - The global crisis, as the theme for the year 2012-2013, this is an attempt to compile some clinical pearls, a few loud thoughts, lingering dilemmas, myriad questions, current challenges, research questions, and tomorrow's optimism!
WHO - Depression will be the second most common cause of disability by 2020, and the first by 2040!
Sadness may be adaptive, in the evolutionary sense, by permitting withdrawal to conserve inner resources or signal the need for support from significant others.
Hippocrates (460-357 BC) described melancholia. The first English text entirely devoted to affective illness was Robert Burton's "Anatomy of Melancholia" published in 1621…. described "causeless" melancholia.
Sartorius, in 2001, predicted the prevalence of depressive disorders would increase in the years to come, citing various reasons. Did it really increase in the last decade?
The international consortium of psychiatric epidemiology interviewed 37,000 adults in 10 countries (USA, South America, Europe, and Asia) using WHO composite international diagnostic interview and found the lifetime prevalence of depression for adults varied from 3% in Japan (the country ravaged by the series of war, earthquakes, tsunamis, economic slowdown, and with high rates of suicide) to 16.9% in USA. Fashion of the day will be to dismiss this difference due to methodological issues. Probing into the reasons for this striking difference in these two developed countries may offer useful insights, data invaluable for primary prevention of depression in the population .
Depression is a risk factor for type II diabetes mellitus, and cardio vascular and cerebrovascular disorders, and a bidirectional positive association has been assumed. Depression is an independent risk factor, and the mediating factor could be hyper cortisolism / Dysregulation of HPA axis.
DSM IV TR makes no provision for family history and history of past episodes. In clinical practice, these factors would strongly weigh in diagnosis of depression.
"Recurrent" episodes of behavioral abnormality - consider always the diagnosis of mood disorder as the first choice. Recurrent schizophrenia is described, but is an uncommon presentation.
Is MDD with psychosis mostly misdiagnosed as schizophrenia?
One-third of depressive patients fulfill the diagnostic criteria for a personality disorder, most commonly of obsessive-compulsive personality.
40% of patients with depressive disorders have anxiety disorders/alcohol abuse as co-morbidity.
Kraeplin believed that no more than 5% of patients with mood disorders have chronicity, whereas the current figures show chronicity going up to 30% - ? Reasons
Akiskal et al ., in 1978 - reported that in a 3-year follow-up of 100 patients diagnosed with neurotic depression, 18 developed bipolarity, 36 had revised diagnosis of endogenous depression, and 42 showed episodic course…. The classification into endogenous - reactive subtypes seems to be passe and mood disorders are best conceptualized as endoreactive, unitary model of Major Depressive Disorder (MDD) .
The increasing clinical diagnosis of depressive disorders should not be dismissed as mere therapeutic fad. External validating strategies, such as genetic and prospective follow-up studies, buttress the broadened concept.
In dysthymic and cyclothymic disorders, representing milder forms/intense temperamental instability, impairment is not due to the severity of mood disturbance per se , but to the cumulative impact of the dysregulation beginning in the early years and continuing unabated or intermittently over long periods. The sub-threshold conditions appear to be fertile terrain for interpersonal conflicts and post-affective pathological character development that may ravage the lives of patients and their families. …