Depression

Major depression is one of the most common affective disorders that can lead to suicide, which ranks ninth among causes of death in the United States.

It is estimated that about 15% of patients with severe depression commit suicide, including those with major depression and depression in bipolar disorder. Depression is also an independent risk factor for disability in patients who underwent myocardial infarction and stroke. The quality of life of patients with major depression or depressive symptoms that do not meet the criteria for major depression (subsyndromal depression) is significantly lower than in healthy individuals and patients with other chronic pathologies.

Affective disorders are one of the main sources of human disability and disability and constitute a serious medical and social problem. Only major depression annually causes economic damage exceeding $ 43 billion, of which $ 12 billion is spent on treatment, $ 23 billion is loss due to absenteeism and unproduced production, $ 8 billion is loss caused by an early death due to suicide. Do not forget about the losses associated with a decrease in the quality of life in these patients, which can not be assessed. To affective disorders include major depression, dysthymia, bipolar disorder (manic-depressive psychosis), cyclothymia and affective disorders caused by somatic and neurological diseases. The relatively high prevalence of affective disorders makes them an urgent problem for all practicing physicians.

[1], [2]

Symptoms of Depression

The main symptoms of major depression include depressed mood, anhedonia, changes in appetite, sleep disorders, psychomotor agitation or inhibition, fatigue, impaired concentration, indecisiveness, repetitive thoughts of death and suicide. The diagnosis of depression can be made if at least five of these symptoms are present for two or more weeks. In addition, for this, other possible causes of these symptoms should be excluded, for example, severe bereavement, medication or other disease capable of causing depression. Contrary to popular belief, suicidal behavior is not an obligatory sign of depression.

Over the past few years, the cumulative prevalence of depression (that is, the proportion of people who have it diagnosed during life) has stabilized, but the average age of debut of the disease has significantly decreased. Depression flows chronically in about 50-55% of cases, and at the time of onset of the disease it is impossible to determine whether this depressive episode will be the only one. If the second episode develops, then the probability of appearance of the third is 65-75%, and after the third episode the probability of the fourth is 85-95%. Usually after the third episode, and sometimes after the second episode, if it was particularly difficult, most doctors consider it necessary to prescribe long-term maintenance therapy.

Diagnostic criteria for the episode of major depression

• Five (or more) of the following symptoms, characterized by a deviation from the usual condition, are simultaneously present for at least 2 weeks; while one of these symptoms should be either

1. depressed mood, or
2. loss of interest or pleasure

Note: symptoms that are undoubtedly caused by somatic or neurological diseases or delusions and hallucinations not associated with an affective disorder should not be included.

• Depressed mood, which is observed throughout most of the day almost daily by the patient himself (for example, in the form of a feeling of sadness or devastation) or by others (for example, according to the sad sight of the patient).

Note: irritability may occur in children and adolescents.

• The marked decrease in interest and loss of pleasure in relation to all or almost all activities for most of the day almost daily (on subjective sensations or observations of others)
• A marked decrease in body weight (not caused by diet) or weight gain (for example, a change in body weight of more than 596 per month) or a decrease or increase in appetite almost daily.

Note:

Children should take into account the decrease in weight gain in relation to the expected.

• Insomnia or pseudospermia almost daily. Psychomotor agitation or inhibition almost daily (according to the observations of others, and not only on subjective feelings of anxiety or slowness)
• Fatigue or loss of strength almost daily
• Decreased ability to think or focus or hesitate almost daily (on subjective sensations or observations of others)
• Repeated thoughts about death (not limited to the fear of death), recurring suicidal ideas without specific suicide plans, or attempted suicide or a specific plan for its implementation
• Symptoms do not meet the criteria for a mixed episode
• Symptoms cause clinically pronounced discomfort or disrupt the life of the patient in social, occupational or other important areas
• Symptoms are not caused by the direct physiological action of exogenous substances (eg, addictive substances or drugs) or a common disease (eg, hypothyroidism)
• Symptoms can not be explained by a reaction to a severe loss; for example, after the loss of a loved one, the symptoms persist for more than 2 months or are characterized by severe functional impairment, painful prejudice in their uselessness, suicidal ideation, psychotic symptoms or psychomotor retardation.

Many patients, especially in general medical practice, complain not of depression as such or of an oppressed mood, but rather of one or another symptom often associated with physical unhappiness. . In this regard, depression should always be borne in mind when examining a patient presenting somatic complaints. Symptoms of depression develop gradually, for many days or weeks, so it is impossible to accurately determine the time of its onset. Often, friends, relatives, relatives notice a trouble earlier than the patient himself.

[3], [4], [5]

Diagnostic criteria of melancholy

Diagnostic criteria of melancholia within the framework of a large depressive episode with a major depression or the most recent depressive episode in bipolar disorder I or II types

• The presence of at least one of the following symptoms at the height of the current episode:
• Lack of pleasure from all or almost all activities
• Indifference to everything that is usually pleasant (the patient does not feel much better, even temporarily, if something good happens to him)
• The presence of at least three of the following symptoms:
• The depressed mood has a special character (for example, a depressed mood is felt as something other than the feelings that experience when a loved one is lost)
• Symptoms of depression are regularly amplified in the morning
• Early morning awakenings (at least 2 hours before the normal time)
• Pronounced psychomotor retardation or, conversely, agitation
• Pronounced anorexia or weight loss
• Excessive or inadequate guilt

[6], [7], [8], [9], [10],

Diagnostic criteria for catatonia

Diagnostic criteria for catatonia in the context of a major depressive episode, a manic episode or a mixed episode with major depression and bipolar disorder of type I or II

• The predominance in the clinical picture of at least two of the following symptoms:
• Motor immobility, manifested catalepsy (with the development of wax flexibility) or stupor
• Excessive motor activity (ie, clearly aimless movements that do not change in response to external stimuli)
• Extreme negativity (obviously unmotivated resistance to any instructions, maintaining a rigid posture despite anyone's attempts to change it) or mutiem
• The peculiarity of arbitrary movements manifested in a posture (arbitrary adoption of an inappropriate or bizarre posture), stereotyped movements, pronounced mannerisms or makeup,
• Echolalia or echopraxia

[11], [12], [13]

Diagnostic criteria for atypical depression

• Reactivity of mood (ie, improving mood in response to real or perceived positive events)
• Two or more of the following symptoms:
• Pronounced body mass increase or increased appetite
• Hypersomnia
• Feeling of non-adherence or heaviness in hands and feet
• The vulnerability to refusals on the part of other people (not limited to episodes of affective disorders), leading to disruption of the patient's life in social or professional spheres
• The condition does not satisfy the criteria of melancholy or Katztonic symptoms during the same episode

These criteria are applicable when these symptoms predominate in the last 2 weeks of a major depressive episode with major depression or the last major depressive episode in type I or II bipolar disorder, or if these symptoms predominate in the last 2 years with dysthymia.

[14], [15]

How to tell the patient the diagnosis of depression?

If a patient is first diagnosed with depression, a number of issues need to be discussed with him. Many patients who did not previously apply to a psychiatrist do not even suspect they have a serious mental disorder. They understand that they are not all right with health, but do not perceive it as a disease and often complain about certain symptoms. To create optimal conditions for the patient, it is important to understand the effect that affective disorders can have on the patient's relationship with the family and people close to him. The patient should be informed, and if possible, also to his relatives and friends, that depression is a disease, and not a manifestation of weakness of character. Many families do not understand what caused such frightening changes in a person close to them, and expect that it will get better once he makes an effort. Therefore, it is important to inform the patient and his family about the features of the disease. In addition, it is necessary, without frightening the patient, to discuss with him the possible side effects of the drugs that will be prescribed to him, and the measures that should be taken when they arise.

The main issues to be discussed with the patient in the diagnosis of major depression

• Characteristic symptoms of the disease
• Depression as a common disease
• Depression is a disease, not a weakness of character
• Non-vegetative disorders - a precursor of high efficacy of antidepressants
• Characteristics of the main side effects of treatment

Differential diagnosis of depression

Differential diagnosis of major depression should be carried out with other affective disorders, in particular dysthymia and, most importantly, with bipolar affective disorder (BPAR). Approximately 10% of patients with major depression in the future develops BPAR; accordingly, the prevalence of BPAP is about 1/10 of the prevalence of major depression. Differential diagnosis of major depression with BPAR is especially relevant in young patients. In addition, differential diagnosis should be made with schizoaffective disorder, schizophrenia, dementia, dependence on psychotropic substances (both prescribed and illegal), as well as with conditions due to somatic or neurological diseases.

If, along with the symptoms of major depression, there is a psychotic symptomatology, then antidepressants should be treated with neuroleptics or electroconvulsive therapy (ECT). Such atypical manifestations as increased appetite, often with a strong craving for high-carbohydrate food and sweets, drowsiness, heaviness in the extremities, anxiety, paradoxical mood swings throughout the day, intolerance to failure require the appointment of drugs that enhance serotonergic activity or monoamine oxidase inhibitors. Melancholy is manifested in the fact that a person ceases to enjoy the majority of classes and becomes indifferent to what previously brought joy. Patients with symptoms of melancholy, even for a short time can not "perk up". Other manifestations of melancholia in the case of major depression include a feeling of depression, a change in mood during the day with a morning increase in depressive symptoms, early morning awakenings, psychomotor inhibition or agitation, anorexia or weight loss, excessive guilt. In depression with psychotic symptoms, delusions and hallucinations can be congruent affective symptoms or, conversely, incongruent (they do not coincide in content with depressive motives). Catatonic symptoms are characterized by psychomotor disorders, negativism, echolalia, echopraxia.

[16], [17], [18]

Relationship of crimes with depression

The connection between depression and crime has not been studied as well as the connection between schizophrenia and crime. According to the survey of the Office of National Statistics on mental disorders in prisons, schizophrenia and delusional disorders are more common than affective disorders.

Depression and mania can directly lead to the commission of a crime. And although as a result of an affective disorder any type of crime can be committed, nevertheless there are a number of well-known associations:

Depression and Murder

Severe depression can cause the subject to think about hopelessness of existence, about the absence of a goal in life and, consequently, the only way out is death. In some cases, homicide may be followed by suicide. In different studies, the levels of suicide after committing homicidal vary. According to West, a significant proportion of suicides are associated with abnormal mental state of subjects, and depressions play an important role here.

[19], [20]

Depression and Infanticide

In such cases, killing a child can be directly related to delusions or hallucinations. On the other hand, the act of violence can be a consequence of irritability due to affective disorder.

[21], [22], [23], [24],

Depression and theft

In severe depression, there are several possible links with theft:

• Theft can be a regressive action, an act that brings peace;
• theft can be an attempt to draw attention to the subject's unhappiness;
• this act may not be a real theft, but a manifestation of absent-mindedness with an unconsolidated state of consciousness.

[25], [26], [27],

Depression and arson

In this association arson can be an attempt to destroy something in connection with a sense of hopelessness and despair, or arson can, due to its destructive effect, alleviate the state of tension and dysphoria of the subject.

[28],

Depression, alcoholism and crime

Long-term alcohol abuse can cause feelings of depression or depression can lead to alcohol abuse. The disinhibitory combination of alcohol and depression can then lead to the commission of a crime, including crimes of a sexual nature.

[29], [30],

Depression and an explosive personality

People who suffer from personality disorders are often less able to cope with their own states of depression. Following the stress that has arisen in connection with the discomfort caused by depression, there may be outbreaks of violence or manifestations of destructive behavior.

[31], [32], [33]

Depression and juvenile offenders

In this association depression can be disguised. Externally, there may be features of theatricality in behavior, as well as manifestations of behavioral disorders, expressed, for example, in constant theft. In the past, there is usually a history of normal behavior and the absence of personality abnormalities.

[34], [35], [36], [37], [38],

Depression facilitated by crime

Some authors pay attention to the phenomenon of depression and tension, which are facilitated through the commission of an act of violence. The history of depression can be traced to the perfect criminal act, and then the subject of depression is lost. From the clinical point of view, this is most often observed in subjects with personality disorders.

[39], [40], [41], [42]

Manic conditions and crimes

In mania, the patient may experience ecstasy with hallucinations or delirium grandeur, which can lead to the commission of a crime. The combination of weak criticism to one's own condition and substance abuse can lead to behaviors that violate social norms.

Medico-legal aspects of depression

Large mood disorders are the basis for applying protection due to psychiatric illness and making psychiatric recommendations. In severe cases, especially with mania, the disorder can be so severe that the subject is unable to participate in the trial. In cases of murder, an adequate measure is a statement of reduced liability, and in the event of the presence of delirium and hallucinations, the subject may fall under the McNoten Rules. Which hospital will take the patient depends on the degree of violence, the willingness to cooperate with therapists and the determination to repeat what was done before.