Depression is a serious disorder it tends to come back again & again
It colors all spheres of life not only person feels sad at office or workplace, also with his friends and at home, are not able to enjoy things which they use to previously.

It should be present minimum for 2 weeks to make diagnosis.
Every 1 out of 6 person will have depression in lifetime.

It requires proper treatment and family support.

Education about it helps a long way to live a great life.

TYPES
Unipolar - Person has only Depression episodes.

Bipolar- Person has both Depression and Mania episodes.

SEX It's two times common in females.

Hormonal causes, childbirth and more social stress in females life.

Sense of helplessness.

AGE
40yrs is the usual age of onset
It can start as early as 20yrs or in some cases in childhood also or in old age for the first time.

FAMILY HISTORY / GENETICS
Child will have 10 to 25% risk if one parent has depression.
Child will have 20 to 55% risk if both parents have depression.
Risk increases with more family members having mood disorders.

MARRIAGE
More common in Divorced or Separated couples

EMPLOYMENT
3 times more common in unemployed people.

COMORBIDITY
Depression is more common with
Alcohol, Panic Disorder, OCD (Obsessive Compulsive Disorder, Social Phobia
Long term medical conditions like Diabetes ,Blood Pressure,Cancer
Stress: Multiple deaths in family
Loss of life partner
Loss parents at young age before 11 yrs

DIAGNOSIS
No lab test is required for making diagnosis.
Its diagnosis is entirely based on symptoms given below

SYMPTOMS
Out the list of 9 symptom given below
5 symptoms should be present to make diagnosis of depression for 2 weeks.
First two symptoms are most important that is Sadness & Asnhedonia

SADNESS OF MOOD:- Person feels like crying for no reason and not feels better even doing that even for hours together, they do it front of strangers also which they themselves feels uncomfortable but still can not control it.
In some cases person wants to cry but is not able to do so. Feels heaviness in head.

ANHEDONIA :- Loss of interest in previously enjoyable activities.
Female who was always fond of shopping is no more interested in shopping even her friends or husband insists on it
Male who always used to love newspaper reading in morning and watching television in evening isn't picking up remote anymore and is not interested in his favorite sports events.
Patient once shared his experience that he even gets irritated with voices of his kids playing which he use enjoy a lot previously and feels frustrated due to it.

GUILT:- Or self blame in extreme case patients believes they are responsible for the wrong things in life of not only themselves but also of their family members.
Many patients wants to die as they feel they are burden on their family.

ENERGY:- Weakness or tiredness is the complaint that person feels, loss of vigour without doing anything or even on small efforts compared to his or her capacity.

CONCENTRATION:- Difficulty in concentrating even on things they used to enjoy at work place or at home.

FOOD :- Usually we expect loss of food intake and weight loss which can be more than 10% of original weight.
No more interest in their favorite food items
In some patients instead of loss of desire there can be increased food intake with weight gain can also be the sign of depression.

Especially they have liking for foods of high sugar content like ice creams, pastries, chocolates, chips or pizzas etc

PSYCHOMOTOR: - Psycho means mind and motor means body like food intake this can also both increase or decrease in patients.
Psycho if decrease means patient complains that the experience decreased number of thought in there mind of feels mind is not working or working very slowly.
Psycho if increased means mind is racing in thoughts of negativity or anxiety.
Motor if decreased, person walks slowly with his head down, eyes looking on ground, dropping shoulders, arms close to his body.
Motor is increased means person is anxious or restless not able to sit comfortably. More common in old age patients.

SLEEP:- Poor quality of sleep, not feeling refreshed.
Difficulty in falling asleep.
Midnight multiple awakening, reduce total time of sleep.
Early morning awakening person wakes up two prior to his waking up time, like someone wakes up 4 am in morning, wants to sleep but keeps tossing in bed.
Lots of dreams usually bad dreams.

SUICIDE:- Depression is the most common cause of committing suicide

It is responsible for 80% of all suicides
60-70% attempt and 10%-15% die in the process
Male, unmarried, unemployed, alcoholic, chronic illness, family history of suicide, poor family support, hopelessness

Common methods is hanging.

Parasuicide:-cutting wrist

ECT (electro convulsive therapy) or electric shock therapy is treatment of choice.If patient of depression is at risk of committing suicide as it acts faster and is more effective compared to medication.
Though some families feel uncomfortable with this method at times but it's very safe and effective.

CAUSES
Serotonin is a neurochemical which is less in brains of patients suffering from depression.
10% of patients are having Hypothyroidism.
Genetics or stressor in life.
Winter season depression is more common as sun exposure is less which leads to less making of happy chemicals in mind.

COURSE
Depression improves within 6 to 13 months even if not treated though in some case can go on for years altogether.
Treatment helps to improve within 4-12 weeks.
5-6 episodes are expected over a period of 20 yrs of illness, though they can vary from person to person.

TREATMENT
Medication , psychotherapy , phototherapy , electroconvulsive therapy

PSYCHOSOCIAL THERAPY :- If depression symptoms are mild

Session length will be 45-60 min twice a week for 3 or more months

TYPES
Cognitive therapy :- It will focus on negative thoughts of patient

Interpersonal therapy:-It will focus on patients current

interpersonal relationships issues like husband-wife , daughter-in-law and mother-in-law boss and employee.

Behaviour therapy:- It focusses on having positive behaviours so patient will receive positive results in life.

MEDICATION:- Patient improves within 4-8 weeks though they have to take medication for a longer period of time.
First time depression period of treatment 6 months to one year.
Multiple episodes may require lifelong treatment or patient
should be symptom free for at least 2-3 yrs to stop medication.

PHOTOTHERAPY / LIGHT THERAPY:- This method is used only for seasonal depression which happens in winter season. Person improves without medication.

ECT (electro convulsive therapy) or electric shock therapy:-This is treatment of choice it patient of depression is at risk of committing suicide as it act faster and is more effective compared to medication.

TIPS FOR FAMILY
Listen to patient rather than giving pep or motivational talks. Depression is an illness, person is not doing it deliberately. When family tries to talk out so person feels more lonely and as if its his mistake.
If we listen instead of telling him what he feels and it's perfectly normal person will feel much better and will share his or her feelings which will be helpful to both the person and his family.
Don't push too much for exercise, yoga or any physical activity.
Just like a person with a fracture or sprain in ankle would not be advised to run or even walk.
Person lack both will and energy to do any such thing so both person and family will feel frustrated.
Don't plan any holiday to set up mood. It will help if there is some adjustment issue with a single person but if this is place depression then even change of place would not be of much help. When put efforts and not get results it's make us even more frustrated.
Better idea is that once person improves then we can go for a holiday together with a happy state of mind

Case Reports

ONE
Female of 27 yrs complains of anxiety and low mood, feels like crying though not able to do so. She complains of heaviness in head, same thoughts revolving in her head again and again. Lost interest in movies and shopping. Sleeps for 7-8 hours though not feel fresh and gets irritable very fast, pick fights on small things which were not her previous nature.
There is a family h/o depression in mother who had been on an on and off treatment.
So she could make out after few weeks. She requires professional help as she has seen similar complaints in her mother previously and came for counseling and treatment. She improved with treatment and advice for need of regular follow up and educated that in case she also has repeated episodes of depression then she may require long term treatment.

TWO
A couple came to clinic. Wife had recently retired as a Principal of school. They have two sons and daughter. All three are married. One son living abroad, rest both son and daughter settled in the same city but living separately.
Since she has retired, there is frequent fight between them. She complains of frequent crying without any reason.
Feels sad and her life without meaning and complains husband not giving her adequate time and attention.
They have changed their home post retirement so no social circle to meet with. She could only talk to her daughter on phone for her emotional issues.
She was advised counseling and socializing more with new neighbors and join new active social groups to keep herself busy and husband to spend quality time with her.
She improved over a period of next few months

THREE
Man of 32 yrs old working in a job, a high performer loves his nature of job. Since last few weeks not feels like the same drive and concentration to work, wife also notices the same. He talks less than previously and don’t even take active interest in playing with their 2 yrs old daughter, which was his favorite activity after coming home.
After a month's time, he loses interest in going to office, crying with no reason even in front of office colleagues which he could understand and would not get any relief even after doing that. At home also he started feeling hopeless and starts feeling that life is worthless and it's better to commit suicide. When he shared this with his family members they panicked and consulted a Psychiatrist and was advised medication and also Electroconvulsive therapy as on enquiry he not only had thoughts of suicide but was planning in detail and had an one unsuccessful attempt.
He improved within next four weeks and started going to his office. He took regular medication for six months than left on his own.
He again had next episode in depression in next year in again in winter season but this time family had better understanding of depression. So they came early and he could be treated fast with medication only.
When a person needs professional help.
Everyone feels low, sad or like crying at times in life that not depression.
Its when things goes on for 2 weeks or more and person is not able to maintain their normal life as previously at work , family or friends than a person requires to consult psychiatrist or psychologist.

Dysthymia is also known as Neurotic depression
Melancholic depression is also known as Endogenous depression
Adjustment disorder as reactive depression as it's in reaction to stress in life
Double depression is Dysthymia plus depression
Persistent depressive disorder is in DSM-5 any depression more the 2 years so both Dysthymia and Double Depression will fall under this
Chronic depression any Depression more than 2 years this will also know fall under Presistent depressive disorder
In ICD-10 Cyclothymia and Dysthymia are classified as persistent depressive disorder
Double depression is a complication of a psychiatric illness called dysthymic disorder, or dysthymia. Dysthymia is a chronic, depressed mood accompanied by just one or two other symptoms of clinical depression (such as low energy or low self-esteem) that lasts at least two years in adults (or one year in kids). This low, dark mood -- sometimes described as a "veil of sadness" -- occurs nearly every day and can sometimes persist for many years. Some people may have this mood disorder for 10 to 20 years or even more before seeking treatment.
Over time, more than half of people with dysthymia experience worsening symptoms that lead to the onset of a full syndrome of major depression superimposed on their dysthymic disorder. This is known as double depression.

Suicide
Incidence of suicide in india rates ranging from 2.36 to 42 per 100,000 populations.
preponderance of male suicides,
the ages of 18 to 30
most common method hanging (acc to studies )

95% of all persons who attempt or commit suicide have a diagnosis of mental disorder
80% depressive disorder
10% schizophrenia, premature cause of death in young patients
5% dementia or delirium.
25% alcohol it comorbid with other psychiatric illness

Multiple attempts
Who attempt more than 3 times rarely die from suicide
Borderline personality disorder
The physician should ask about a history of psychiatric disorders. the patient should be asked about a history of suicidal ideation and suicide attempts.

Asking patients about suicide will not give them the idea or the incentive to commit suicide. most patients who consider suicide are ambivalent about the act and will feel relieved that the clinician is interested and willing to talk with them about their ideas and plans

25/1 ratio of attempts to completed suicides
Men commit 4 times more use firearms, hanging or jumping
Female attempt 4 times more poison
Peaks at 45 in men , 55 in females
unmarried , unemployed increased risk

Doctors
Psychiatrist top on list
ophthalmologist, anesthesiologist
other specialties are not far away
Antisocial personality disorder
Serotonin metabolites are less in the lumbar CSF with suicidal behavior

Para suicide for emotional blackmailing do not wish to die actually
commonest method
wrist cutting first preference
arm , thighs , legs , face , breasts , abdomen

Paradoxical suicide with antidepressants
risk actually increases

Durkheim theory
Egoistic:- not strongly integrated in society
Altruistic:-excessive integration in society like suicide bombers
Anomic :- integration in society is disturbed like in economic meltdown
Surviving suicide
Suicide survivor refers to those who have lost a loved one to suicide, its toll is greater than by other death
Depression with suicidal risk ECT in first line treatment
Risk factors
Male
> 45 yrs
Single , divorce
Unemployed
Homosexual
Alcohol
Family h/o of suicide
Chronic illness
Hopelessness
Hallucination