Depression - Symptoms, Causes, and Treatment - NEET PG Psychiatry

Depression is considered an important topic for NEET PG exam preparation because it is a prevalent mental health disorder and requires a comprehensive understanding for the effective management and treatment of patients. Furthermore, topics related to depression, such as pharmacotherapy and psychotherapy, are commonly tested in the NEET PG exam.

Overview

According to NMHS depression is the most common psychiatric disorder in India. Most common psychiatric disorder in the world is Anxiety disorder.

• Female: Male= 2:1 (Multiple factor: Biological or Social)
• Mean age of onset: Middle age
• Most common cause of DALYs amongst all psychiatric disorders (Disability Adjusted Life Years)

Symptoms

Listed below are the primary symptoms of depression: 

• Mnemonic: SIGECAPSS
  • S - Sadness of mood/Depressed mood (Persistent and Pervasive)
  • I - Interest (Loss)/Loss of pleasure (Anhedonia)
  • G - Guilt/Feeling of worthlessness 
  • E - Energy (Loss)/Fatigue
  • C - Concentration (loss)
  • P - Psychomotor agitation/retardation
  • A - Appetite (Loss) with weight changes
  • S - Suicidal thought 
  • S - Sleep disturbances (Decreased/Increased) - Early morning insomnia is specific for depression - waking early and time shifts up to 2 hours before.

If symptoms are present for > 2 weeks, diagnosis of depression is made.

Important information Significant weight gain/loss If there is a change in weight of > 5% in one month

Specific symptoms with depression: Specifiers

• Psychotic features
  • Delusions/Hallucinations: If present along with depression, then in management antipsychotics are added
• Atypical features
  • Reversed biological feature (increased appetite, weight and sleep)
  • Mood Reactivity present (Mood improves with positive events)
  • Leaden paralysis: Subjective feeling of heaviness of limbs
  • Extreme sensitivity To Interpersonal Rejection.
    • Sensitivity to even slight things
    • E.g.: Person feels disturbed if someone rejects him or criticize him.
• Important Information
  • Patient with atypical depression respond better to SSRIs, and MAOIs better than TCAs.
• Melancholic features (Involutional melancholia)
  • Significant biological symptoms (significant anorexia, weight loss, early morning awakening)
  • Lack of mood reactivity and Anhedonia
  • Depression worse in morning, distinct quality of mood (feeling of misery)
  • Excessive guilt and marked psychomotor aviation and retardation
• Important Information
• There are higher chances of developing psychotic features and possibility of suicide attempts and completed suicides are more in melancholic depression.

Etiology of depression

1. Neurotransmitter disturbances
   • Serotonin deficiency 
   • Serotonin, Norepinephrine and dopamine deficiency
2. Psychological theory (Cognitive theory)
   • Given by Aaron Beck: i.e. negative thought in depression sustains the depression itself.

Beck’s cognitive Triad

• Negative view of self (Ideas of worthlessness)
• Negative view of environment (Ideas of helplessness)
• Negative view of future (Ideas of hopelessness) - this is more important because it is associated with increased risk of suicide.

Treatment

Treatment of depression is as follows: 

Antidepressants

• SSRIs, SNRIs, TCAs, MAOIs, Atypical antidepressants.
• The first antidepressants and M/C used antidepressants are SSRI (Escitalopram) because side effect profile of SSRI is better as compared to other antidepressants
• Antidepressants are chosen on the basis of side effect profile

Important information  SSRIs: Selective Serotonin Reuptake Inhibitors  SNRIs: Serotonin Norepinephrine Reuptake Inhibitors TCAs: Tricyclic Antidepressants MAOIs: Monoamine Oxidase Inhibitors

TCA toxicity

1. Problem with TCAs
   • Side effect: Anticholinergic action, antiadrenergic action, antihistamine action 
     • Avoided in certain disease like Angle closure glaucoma
   • Safety: If excessive, leads to Toxicity
2. Action of TCAs: It blocks sodium channels
3. TCA toxicity
   • Hypotension, tachycardia, altered sensorium, respiratory depression & seizures (CVS and CNS manifestation)  
   • Dry mouth, blurred vision (Anticholinergic action) 
   • Metabolic acidosis (Due to hypoxia)
   • ECG: Prolonged PR, QRS and QT interval, right axis deviation
   • Use I.V. sodium bicarbonate (if QRS more than 100 milliseconds)

SSRI Side Effects

• GI side effects (Most common)
• Sexual dysfunction (Most common long-term effect)
  • Loss of libido
  • Erectile dysfunction
  • Delayed ejaculation
    • T/t of premature ejaculation- give SSRIs
    • To avoid sexual dysfunction give other antidepressants like Mirtazapine, Bupropion  
• Sweating, vivid dreams (Dreams in the night and don’t feel fresh in the morning)
• Weight gain
• Discontinuation symptoms of antidepressants.
• M/C associated with venlafaxine (SNRI), short acting SSRIs (paroxetine, fluvoxamine)
• Flu like symptoms, nausea, agitation, anxiety and insomnia
• Important Information
• Tapering of antidepressants is to be done before discontinuation, never be abruptly stopped.
• Electroconvulsive therapy 
  • Immediately starts working
    • Depression with suicide risk
    • Depression with stupor 

3. Cognitive behavioral therapy (psychotherapy)
   • Try to fix the negative thoughts

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