Treatment for Depression: Symptoms, Diagnosis, and Therapy Options

Everyone has days of sadness and low mood. These phases usually pass quickly. However, if the low mood persists for more than two weeks, it might indicate depression.

Clinical depression, also known as Major Depressive Disorder (MDD), is a psychiatric condition characterized by persistent feelings of sadness, fatigue, loss of interest in activities, and sleep deprivation.

Depression can affect anyone, with the risk varying based on triggers. When depression strikes, the reasons are often elusive. Depression symptoms can seemingly appear out of nowhere, leaving many feelings guilty and perplexed, thinking, “Everything is fine, so why do I feel so awful?” Accepting the illness can be challenging initially, with sufferers often feeling misunderstood. Well-intentioned advice like “snap out of it” or comforting words like “cheer up, it’ll get better” are unhelpful.

Treatment for depression requires professional help to diagnose the condition and choose the proper therapy.

Symptoms of Depression: Recognizing the Warning Signs

Depression can take a severe toll on one’s life, leading to feelings of persistent sadness, exhaustion, and disinterest in activities and social withdrawal. Untreated depression has devastating impact on individual’s well-being, including decreased quality of life and increased suicide risk. People with depression are mor likely to die on high blood pressure, diabetes, stroke, or heart attack.

Therefore, understanding the symptoms, levels of severity, and available treatment for depression in Dubai is essential for effective management and recovery. With proper care and knowledge, therapy for depression can remove the symptoms, leading to a full recovery.

Depressive symptoms include:

Main symptoms:

• persistent low mood
• loss of interests or pleasure
• lack of energy

and

Secondary symptoms:

• Poor concentration and attention
• Low self-esteem and self-confidence
• Feelings of guilt and worthlessness
• Excessive worry about the future
• Thoughts or acts of self-harm or suicide
• Sleep disturbances
• Decreased appetite

Physical Symptoms Caused by Depression

Physical discomfort can also contribute to diagnosis. Headaches, back pain, dizziness, and digestive issues might be the somatic symptoms caused by depression.

Physical complaints that may indicate depression are:

• General physical weakness and fatigue
• Sleep disturbances (difficulty falling asleep and/or staying asleep)
• Appetite changes, gastric discomfort, weight loss, digestive issues like constipation or diarrhoea
• Headaches or other bodily pains such as backaches
• Sensation of pressure in the throat and chest (known as “globus sensation”)
• Shortness of breath and disruptions in heart and circulatory function, like arrhythmias or palpitations
• Dizziness, visual disturbances, and eye fluttering
• Muscle tension and sudden sharp pains
• Loss of sexual interest, absence of menstruation, impotence, sexual dysfunction

Diagnosis of Depression

Depression is one of the most common psychiatric illnesses that affects millions of people. Proper diagnosis and therapy of depression is crucial for an individual’s recovery. However, misdiagnosis is possible. Depression is difficult to diagnose as there are no precise laboratory or neuroimaging tests to confirm the diagnosis.

Diagnostic Criteria of Depression

Depression is diagnosed when there are at least two primary and two secondary symptoms present for a minimum of two weeks. Assessment takes into account not only patient’s current emotional state but also the course of the past few weeks.

Alongside typical emotional stressors, physical complaints can also indicate depression. Such symptoms like shortness of breath or heart rhythm disturbances might have psychological causes.

Making Psychiatric Diagnosis at CHMC Dubai

The presence of symptoms of depression doesn’t necessarily confirm the diagnosis. Many of such symptoms might align with other mental or physical disorders. Before securing the diagnosis of depression, a thorough assessment should exclude other disorders.

The diagnosis of depression is based on the criteria outlined in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5,) mostly used in the US, or the International Classification of Diseases (ICD-10) deployed worldwide, among others in Europe.

Steps in Diagnosing Depression

Depression requires proper diagnosis which can be secured by a psychiatrist or psychologist. The psychiatric interview can start with “Two-Questions Test” giving the physician basic information about patient’s status.

Identifying depression is not always straightforward. Many individuals experiencing depression find it challenging to discuss their emotional state voluntarily. They often struggle to articulate their problems. One reason for this difficulty is that vague physical complaints can be linked to depression. Consequently, some affected individuals mistakenly attribute their symptoms to a physical illness.

Depression requires a proper diagnosis, which can be secured by a psychiatric assessment. Diagnosis of severe depression requiring treatment with medication typically involves a few steps: a conversation with the psychiatrist, a physical examination of the patient, a laboratory test, an ECG, and, in some cases, CT or MRI scans.

The diagnosis of depression at CHMC Dubai is based on the criteria outlined in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), mostly used in the US, or the International Classification of Diseases (ICD-10) deployed worldwide, among others in Europe.

The “2 Question Test”

An initial indication of depression can come from a simple test known as the “Two-Question Test”:

• Have you frequently felt down, sad, or hopeless in the past month?
• Did you have noticeably less interest and joy in activities you typically enjoy over the past month?

The answer “yes” to both questions may indicate depression. In that case, the psychiatrist will further assess the signs of depression by engaging in conversation and asking about specific symptoms.

Initial Conversation with the Patient (Anamnesis)

The most crucial tool for determining the diagnosis of depression and assessing its severity through conversation with the patient. The more openly and accurately the exploration, the better the assessment of the depressive state.

The conversation may begin with a more structured interview containing a set of questions or in form of open-ended questions, such as why the person visits the doctor, how he feels, or what are the complaints.

The open approach allows the patient to incorporate better own thoughts and observations into the conversation. However, the patient may also want to discuss entirely different matters initially, such as recent experiences or challenging life situations. The therapist should approach the patient more flexible adjusting the interview to the circumstances.

During the conversation, the psychiatrist or psychologist pay attention to other details such as behaviour, clothing, or language. A soft-spoken tone, a lack of emotional expression, or a slouched and weary posture can provide clues about the individual’s condition.

Diagnosing depression, especially in individuals with severe physical or mental illnesses or in older adults, can be challenging. In such situations, it can be helpful to also interview family members or close caregivers.

Physical Exam

The objective of physical exam, laboratory test and other investigations, described below, is the exclusion of underlying physical illnesses, which can mimic depression.

Physical exam consists of:

• General physical exam: assessment of patient’s general health status (depression may be linked to an underlying physical health problems).

• Neurological exam: allows to roll out major problems of the central nervous system.

Laboratory tests

Evaluating the status of the patient before starting the treatment excluding different health issues. In case of starting treatment with medication the initial result is a benchmark for further controls.

ECG (Electrocardiogram)

By using ECG, we exclude pre-existent heart problems. A “native” ECG is also a point of reference for further controls under medication.

Additional Diagnostics

A more profund investigation will be needed in case of severe mental disorders like psychosis or bipolar disorder. Such diagnostic includes brain scan (CT-scan or MRI) and the record of the brain generated electrical activity EEG (Electroencephalogram).

Therapy Concept and Treatment Phases for Depression

Modern treatments can often quickly heal or relieve depressive episodes, significantly improving quality of life. However, over 50% of cases are recurrent or chronic, with causes that remain unresolved. Each episode increases the risk of another, and stopping treatment raises the likelihood of recurrence.

Treatment mainly involves antidepressants, psychotherapy, or a combination of both. For mild to moderate depression, psychotherapy is as effective as medication, though it takes longer to show effects. For severe episodes, combined therapy is more effective than either medication or psychotherapy alone. In mild depression (mild episodes, dysthymia), antidepressants are less effective than in severe cases, making psychotherapy the preferred option.

Whether outpatient treatment is possible or a hospital stay is necessary depends on factors like the type and severity of depression and the individual’s suicide risk. For psychotic depression, or for those in suicidal patients, hospitalisation can be the only option. The goals of treatment vary depending on the stage of the illness.

1. Acute Therapy for Depression

Acute therapy should begin as soon as an acute phase of the depression appears. It continues until the acute symptoms have significantly improved. The acute therapy typically lasts four to eight weeks. In this phase, the focus is on educating the patient about the illness, the treatment plan, and the importance of taking medications. This “psychoeducation” is essential, along with maintaining close contact with the psychiatrist, who is available to answer questions and encourage patients to take prescribed medications regularly. It’s important for patients to know that antidepressants often take a few days to weeks to show effects.

2. Maintenance Therapy for Depression

Maintenance therapy follows acute therapy and aims to stabilize the patient to prevent a relapse. Relapse means the return of symptoms before full recovery has been achieved. If symptoms reappear after the person has returned to their original state of health, it’s considered a recurrence. The goal of maintenance therapy is to stabilize patient’s state for at least four to six months. It’s crucial to recognize early warning signs of a relapse and know strategies to prevent it.

3. Prevention of Recurrence (Relapse Prevention) for Depression

Prevention of recurrence begins once the patient’s mood has stabilized. Its goal is to prevent another acute episode in long term. The duration of the relapse prevention depends on the number and severity of past depressive episodes. Generally, patients should not stop the prescribed therapy on their own, and a regular daily rhythm of rest and activity should be established and maintained.

Involving a partner or family members is important in treating depression. Relatives should be informed about the symptoms, treatment options, and prognosis (psychoeducation). Equiped with such knowledge they can support the patient, encourage continuation of treatment, and protect against relapse.

Adjusting Treatment to Severity of Depression

Treatment options vary for each severity level. Hence, it’s crucial to identify all signs of the illness through thorough questioning. Each depression is unique. It differs in intensity and course. Severity levels can be mild, moderate, or severe, based on the number and duration of main and secondary symptoms. The therapy of depression should be adjusted to the level of severity. While mild depression can be treated only with psychotherapy, the higher grades require the use of medication.

Treatment for Depression with Psychotherapy

In patients treated only “biologically,” i.e. with medication, the symptoms can appear again despite using the same dosage of the medication. Consequently, adding the psychotherapy is a necessary part of an effective treatment, improving by several times the chance for a full recovery.

Clinical psychologists offer psychotherapy, or “talk therapy”, and have degrees in psychology and significant postgraduate training. Psychologists avail themselves of evidence based psychotherapeutic treatment methods.

There are variety of psychotherapeutic methods. The majority of them belong to two psychotherapeutic branches: psychodynamic and behavioural therapy.

Patient-Therapist Relationship

The warranty of a successful psychiatric and psychotherapeutic treatment is a trustworthy relationship with the psychiatrist and/or psychologist.

The patient should be transparent with the psychiatrist reporting honestly about his worries, work, and private circumstances, as well as possible side effects of the medication. Based on the feedback the psychiatrist can adjust the medication.

One of the common reasons for failing the therapy is changing or discontinuing the medication by the patient himself. Firstly, the risk of uncontrolled stopping the medication can be the reappearance of the depression. Secondly, by sudden discontinuation of the medication will trigger unpleasant symptoms such as mood swings, dizziness, or nausea. Needless to say, that any changes of medication should be discussed and monitored by the psychiatrist.

Cognitive-Behavioral Therapy in Treatment for Depression

Cognitive behavioral therapy combines two therapeutic approaches:

• initially symptom reduction and then their full disappearance
• improving and then restoring daily routine
• preventing relapse after patient’s full recovery

Cognitive Therapy

According to cognitive therapy, it is often not the things and situations themselves that cause problems, but rather the meaning we attach to them. Our personal perspective can be a crucial starting point for change.

Behavioral Therapy

Behavioral therapy is based on the assumption that behaviours can be learned and unlearned. The therapeutic goal is to identify problematic behavioral patterns, work with them, and bring about change.

The core approach of CBT (Cognitive Behavioural Therapy) is based on the idea that problems are the result of the way people interpret situations, thoughts, and feelings. CBT addresses the symptoms, giving the patient insight about the triggers in “her and now.” This allows the patient to control the patterns of his thinking and behaviour causing the symptoms. It helps the individual identify thoughts that make them feel bad (e.g., I am not good enough).

Treatment with Psychodynamic Psychotherapy

Psychodynamic psychotherapy relates to several methods of in-depth psychotherapy. These are classical psychoanalysis, psychoanalytical psychotherapy, and different modifications of this methods.

Despite the different approach, just as cognitive-behavioral therapy, psychodynamic therapy also wants to bring about changes in behaviour. Unlike CBT, psychodynamic psychotherapy places a large emphasis on the psychic layer not accessible to the consciousness, especially on the unresolved conflicts. Conflicts are upsetting contents such as aggressive impulses and anti-social desires “stored” in the unconscious. However, even though they are not accessible to our conscious perception, they influence our feelings and behaviour.

A key requirement for psychoanalytic-based therapy is a willingness to engage deeply with past, such as early childhood experiences, current relationships and current defence mechanisms.

Reducing the intensity of the conflict, creating the underlying tension, leads to symptom reduction. Making unbearable feelings conscious and employing the Ego (the conscious part of the psyche) in understanding cause and effect brings about healing.

Efficacy of Psychodynamic Treatment for Depression

Psychodynamic psychotherapy has not been studied as extensively as behavioural therapy in the treatment for depression. Even though psychodynamic psychotherapy, including the eldest technique called “psychoanalysis”, has a long-standing history, the empirical research on its effectiveness is less large. Despite the higher number of studies referring to behavioural methods, those done for psychodynamic psychotherapy prove its efficacy. The main reason for the lower volume of research related to psychodynamic methods is explicable by the therapy setting. The psychodynamic psychotherapy done by an analyst in his private practice is less accessible for empiric evaluation.

Depression Treatment with Interpersonal Psychotherapy

Interpersonal Psychotherapy involves meeting with a group of other people who have been through the same or a similar traumatic event. It can be easier to talk about what happened if you are with other people who have been through a similar experience. An open trial of interpersonal psychotherapy reported high rates of remission from symptoms.

Treatment with Systemic Therapy

Systemic therapy places great importance on social relationships, such as those within the family, circle of friends, or workplace, as they can contribute to the development of depression. During therapy, efforts are made to improve communication within a family, for example. This is intended to help alleviate depressive symptoms.

Treatment of Depression with EMDR

Francine Shapiro developed and studied EMDR (Eye Movement Desensitisation and Reprocessing), which is a form of psychotherapy. This is a technique that uses eye movements to help the brain access and integrate the traumatic events “pushed” by sudden trauma (for example, by war trauma or accidents) in the unconscious in their raw, unprocessed shape. Psychologists use the eye movement to facilitate emotional processing of memories to attend to more adaptive information.

Psychotherapy for Depression in Older Adults

The global increase in life expectancy is undeniable, with approximately 11% of the world’s population currently aged over 65. In some societies, this percentage has already surpassed 30%.

While longer life spans are a positive development, they come with implications for mental health. Depression takes central stage among individuals aged 65 and above. Age-specific psychosocial factors, such as loss of significant relationships and social isolation, likely contribute to this phenomenon.

A distinction is often made between full-blown depressive episodes and subsyndromal depression since many older individuals exhibit depressive symptoms that do not meet the severity criteria for a full episode.

Beginning with Sigmund Freud psychotherapy for older adults were considered as unsuccessful. Freud was arguing that old people are less adaptable not being able to change their mindsets. However, the recent studies proved efficacy of various psychotherapeutic technics, including psychodynamic methods, in treatment of depression in older adults.

Psychotherapy for Older Adults with Depression

Depression in older adults is a significant mental health concern that can have debilitating effects on individual’s well-being and overall quality of life. While pharmacological treatments are commonly employed, in recent years psychotherapy has emerged as a valuable intervention.

This article explores the various psychotherapeutic methods used to address depression in the elderly, including their effectiveness and suitability.

Psychotherapy with older depressive patients is an effective treatment for depression. Psychotherapy plays a crucial role in this group offering them a therapeutic space to explore their emotions, thoughts, and behaviours. This approach is particularly valuable when patients struggle with events such as loosing friends and peers, financial matters or while facing decisions about permanent placements, such as nursing homes.

Additional problems are caused by age-specific physical illnesses representing a loss of personal resources. Nevertheless, even older adults with cognitive impairments, up to mild comorbid dementia, can benefit from psychotherapy.

Effective treatment for depression older adults varies depending on symptoms severity and typically involves individual psychosocial interventions, psychotherapy, and pharmacotherapy, with the involvement of family members.

Types of Psychotherapy for Depression in Older Adults

There are several psychotherapeutic approaches explored for their efficacy for treating depression in older adults.

Cognitive Behavioral Therapy (CBT)

CBT has shown substantial effectiveness in treating depression in older adults, with larger effect sizes compared to control groups. Cognitive Behavioral Therapy addresses dysfunctional thoughts that are often age-related, such as “change is impossible in old age” or “depression in old age is normal.”

Interpersonal Psychotherapy (IPT)

IPT is a structured, problem-oriented approach that integrates elements of psychodynamic theories and CBT. It focuses on interpersonal conflicts, social deficits, grief, role changes, or transitions that contribute to depression. Interpersonal Psychotherapy is particularly well-suited for addressing challenges often encountered in later life. Studies demonstrate its effectiveness in older adults, especially when combined with antidepressants.

Psychodynamic Therapies

Psychodynamic therapies, rooted in Freud’s psychoanalytic theory, have also been examined in older depressive patients, with evidence mainly supporting focal therapy. Focal therapy targets specific, symptom-triggering conflicts, offering more focused treatment with shorter duration and fewer sessions.

Despite the evidence favoring CBT over psychodynamic approaches, it’s important to note that psychodynamic therapies are still effective and adaptable for patients with good cognitive performance. These insight-oriented therapies are rooted in psychoanalytic theory and have been proved effective for treatment of depression in older patients.

Reminiscence-Oriented Therapies

Reminiscence therapies are mostly used to provide counselling to older adults suffering of depression. They can be also employed as an intervention technique for patients with cognitive deficits in such conditions as Alzheimer’s disease.

According to the American Psychological Association (APA), reminiscence therapies are described as the use of positive aspects of personal life stories to enhance psychological well-being. This therapeutic method emphasizes a profound respect for the life journeys and experiences of older individuals with the goal of promoting and maintaining their mental health. Reminiscence-oriented therapies vary in terms of structure, thematic scope, and goals, making it possible for nursing professionals to administer some of these interventions.

Most of the research on reminiscence therapy has centred around the elderly population, particularly those suffering of depression. These commonly used interventions have less robust evidence. Most studies have focused on subsyndromal cases, limiting their applicability to major depression.

Web-Based Cognitive Behavioral Therapy

Online interventions have been examined and found to have significant effects on depression symptoms in older adults. Taking in consideration restrained mobility of older patients, this approach provides a flexible and accessible means of delivering psychotherapy.

“Third-Wave” Cognitive Behavioral Therapies

These therapies expand upon traditional CBT and include approaches like Acceptance and Commitment Therapy (ACT), Cognitive Behavioral Analysis System of Psychotherapy (CBASP), and Mindfulness-Based Cognitive Therapy (MBCT). Although less researched in older populations, these approaches have shown promising effects. Acceptance and Commitment Therapy encourages acceptance of unwanted thoughts and emotions, while Mindfulness-Based Cognitive Therapy incorporates mindfulness-based stress reduction.

Psychosocial Interventions

While psychotherapeutic and pharmacotherapeutic approaches have robust evidence, there is a shortage of studies regarding the effectiveness of psychosocial interventions. Psychosocial interventions aim to reduce depressive symptoms, lower suicide risk, maintain social connections, and enhance self-efficacy. Recommendations categorize interventions into low-intensity (e.g., guided self-help or physical activation) and high-intensity (e.g., psychoeducation) approaches. Psychoeducation also focuses on involving the patient’s family, recognizing their increased risk for depression and need for professional support.

Treatment for Depression with Medication

Medication is the fastest method of treatment of depression. However, the best long-term effect can be achieved by combining medication with psychotherapy.

Brain nerve cells use various neurotransmitters to transmit signals. While not all details are known, experts believe that in depression, the balance of certain neurotransmitters, such as serotonin, noradrenaline, dopamine or, glutamate are altered and some nerve connections are inhibited. They are different groups of medication influencing the neurotransmitters and used in treatment of depression. However, the main medication used in the treatment are antidepressants.

Treatment for Depression with Antidepressants at CHMC in Dubai

From a neurobiological point of view, depression is caused by an imbalance of certain brain neuromodulators. Antidepressants aim to improve the imbalance, lifting the symptoms of depression.

Modern pharmacological research has developed several antidepressants with different courses of action. The two biggest and most frequently used groups of antidepressants are SSRIs (Selective Serotonin Reuptake Inhibitors) and SNRIs (Serotonin-Norepinephrine Reuptake Inhibitors).

Psychiatrists should involve their patients in a dialogue to create an understanding of the effects and potential side effects of the prescribed medications.

Course of Treatment for Depression with Antidepressants

While there are many different antidepressants, it is difficult to predict how well a specific medication will help in a particular case. Therefore, at the beginning of treatment, psychiatrists suggest a medication that they consider most effective and well-tolerated. If the medication does not work as expected, it is possible to switch to another one. Sometimes, various trials with medications are necessary to find the most suitable substance. 

Maintaining the course of antidepressant medication is crucial even when a patient experiences an improvement in their condition. In fact, continuing treatment for a minimum of four to nine months, even after symptoms have abated, can substantially reduce the likelihood of a relapse. When discontinuing antidepressants, it is essential to do so gradually to manage potential side effects that may arise during this phase.

When to Use Antidepressants

Studies have shown that the benefit of treatment with antidepressants depends on the severity of depression: the more severe the depression, the more the benefits outweigh the drawbacks. This means that antidepressants are effective for chronic, moderate, and severe depression. They use is less successful for treatment of mild depression or dysthymia.

However, even in cases of mild depression, where the efficacy of antidepressants is somewhat diminished, they might still prove valuable. This is particularly true if the individual has experienced more severe depressive episodes in the past or has responded positively to antidepressant medication previously.

Advantages of Antidepressants

It’s essential to recognize that antidepressants are non-addictive, dispelling concerns of dependence or the need for escalating doses to achieve the desired therapeutic effect. However, to minimize the risk of unwanted side effects, it is imperative to adhere to a consistent medication regimen. Any adjustments to the dosage should only occur under the guidance and approval of a psychiatrist.

Antidepressants offer several advantages in the treatment of depression. They demonstrate remarkable efficacy, particularly for individuals grappling with moderate to severe forms of the condition. Furthermore, they typically manifest their therapeutic effects relatively quickly, typically within approximately two weeks. Importantly, the treatment regimen is relatively undemanding in terms of time commitment. Additionally, a variety of antidepressant formulations exist, each tailored to address specific symptoms, allowing for a personalized approach to treatment.

Disadvantages of Antidepressants

However, it’s essential to acknowledge the potential drawbacks associated with antidepressants. Depending on the specific medication, individuals may experience side effects such as nausea, weight gain, digestive disturbances, drowsiness, or sexual problems. These side effects are most common at the onset of treatment, with roughly half of all patients reporting transient discomfort. In some cases, the side effects can be so burdensome that treatment must be discontinued. Moreover, it’s essential to recognize that antidepressants do not address the underlying life issues that may have contributed to the development of depression, such as work-related stress or relationship difficulties. Finally, individuals who have undergone antidepressant treatment are at a higher risk of experiencing a relapse compared to those who have received psychotherapy.

Course of Treatment with Antidepressants

Antidepressants are taken daily. In the first weeks and months, the goal is to alleviate symptoms and ideally make the depression disappear. Once this goal is achieved, the treatment is continued for at least 6 to 9 months. This so-called maintenance therapy is important to prevent relapses. Sometimes the medications are taken for even longer to avoid relapses (relapse prevention).

The duration of intake depends, among other things, on how the symptoms develop and whether there is an increased risk of relapse. Some people make need antidepressants for many years.

Psychiatric Monitoring During Treatment with Medication

Regular psychiatric visits are important during the treatment with medication. The psychiatrist will ask whether the symptoms have improved and if any side effects have occurred. If necessary, the medication type and dosage will be adjusted.

Under no circumstances the patient should medicate himself. This can result in insufficient effectiveness, more side effects or even in overdosing. Unlike many sleep aids and antidepressants need weeks to develop full efficacy. Abruptly discontinuation of antidepressants leads often to sleep disturbances, nausea, or restlessness. It can also happen, that few days later the patient might feel better. This leads him to the conclusion that he is healed and/or that the medication wasn’t effective. However, days or weeks later the depression can reoccur even more pronounced then at the beginning.

Towards the end of the treatment, the medication dosage should be gradually reduced over several weeks under strict psychiatric monitoring.

Predictability of Genetic Testing for Finding the Proper Antidepressant

Antidepressants remain the first-line treatment for major depressive disorder (MDD), but responses to antidepressants vary widely between individuals. There is still a lack of predictive treatment response, which means that the choice of the most effective antidepressant for a specific patient can be identified only by trial and error.

The currently available genetic tests trying to predict the effectiveness of a particular antidepressant are not showing the expected accuracy. The lack of predictability of those tests is explicable not only by the interaction of a variety of different genes but also by the role of an external stressor. Such evidence leads to the conclusion that the onset of depression is a complex and heterogeneous process combining genetics and environmental factors.

Suicide Risk in Depression

The most severe consequence of depression is suicide. Between 10% to 15% of patients with recurrent severe depressive episodes die by suicide. Those at the highest risk include individuals in challenging psychosocial circumstances, such as divorced or solitary individuals, those who abuse alcohol or drugs, older adults, and those with a history of suicide attempts. Suicides often occur at the beginning or end of an episode when mood is low but motivation remains high, providing ample energy for dangerous actions.

Recognizing and addressing the profound impact and potential consequences of depression is crucial for effective intervention, treatment and support for those affected by this debilitating condition.

Treatment for Depression of Suicidal Patients

Suicidal thoughts can appear in severe episodes of depression. Such patients should be immediately hospitalized and treated under close supervision by a psychiatrist and nurses.

Suicidal ideations can appear at every age but the most vulnerable group are older adults facing isolation, physical ailments and partner loss.

Successful treatment is key to suicide prevention.

International Treatment Recommendations for Depression

Following the international therapy recommendations for depression therapy set by the World Federation of Societies of Biological Psychiatry (WFSBP) summarizing evidence-based therapeutic strategies, a thorough diagnostic assessment by a specialized medical professional is crucial.

These therapy recommendations systematically assess evidence for treating major depression. They offer meaningful clinical recommendations. Physicians treating these conditions should use them. Data come from treatment recommendations, meta-analyses, and Cochrane Library searches.  

This assessment is based on four fundamental elements in the overall treatment of depressive episodes, taking into account clinical factors like symptom severity, disease progression, and patient preferences (watchful waiting, medication, psychotherapeutic treatments, combination therapy).

A comprehensive approach, considering severity and tailored therapies, is vital in addressing depression. Psychotherapy, when applied appropriately, plays a crucial role in the treatment landscape of depression, offering hope for improved mental health outcomes in the years to come.

Maintaining medication adherence is crucial for the success of maintenance therapy for depression. Therefore, establishing a strong therapeutic alliance and providing education to both patients and their families are fundamental aspects of psychiatric care. These educational efforts should cover various topics, including the typical course of the illness, treatment options, medication effects and potential side effects, the use of daily self-report instruments to monitor mood and early signs of relapse, long-term expectations, and the eventual conclusion of treatment.

When a person is struggling with depression, it can be challenging for their family to know how to provide the right support. Well-intentioned advice may not always be helpful, and it’s crucial to approach the situation with sensitivity and understanding.

Watchful Waiting

For mild depression, the “watchful waiting” approach is suitable. Treatment begins only if the condition worsens. Patients are supervised by their doctor, typically a general practitioner. The doctor assesses symptom changes during regular check-ups. If no improvement or deterioration occurs after two weeks, treatment should commence. Supportive conversations, general counselling, education about the condition, guided self-help, such as through self-help books or online programs, and problem-solving approaches can be offered initially before considering medication or psychotherapy.

IMPORTANT: Watchful waiting is only suitable for patients with mild depression. Prompt treatment initiation is necessary for moderate or severe depression!

In summary, mild depression can resolve without intervention, but consulting a healthcare professional is wise. Various treatments, including psychotherapy and medication, are available for more severe cases. Watchful waiting is an option for mild depression, but prompt treatment is crucial for moderate or severe depression. Each individual’s journey to recovery is unique, and seeking help is the first step towards healing.

When to Treat Depression with Psychotherapy?

In the recommendation “Unipolar Depression,” the general recommendation of psychotherapy stands out, depending on the severity, either as monotherapy or combination therapy. Psychotherapy plays a highly valued role in the acute treatment of unipolar depression. A closer examination of criteria and circumstances for practical application is essential.

Numerous Cochrane reviews confirm the effectiveness of psychotherapy. Following psychotherapeutic approaches are validated in depression treatment:

• Cognitive Behavioral Therapy (CBT)
• Interpersonal Psychotherapy (IPT)
• Cognitive Behavioral Analysis System of Psychotherapy (CBASP)
• Psychodynamic short-term psychotherapies

When to Combine Medication with Psychoterapy

Combination therapy involves using both antidepressants and psychotherapy simultaneously. This approach is employed when a single treatment alone isn’t effective or when severe depression hinders participation in psychotherapy until medication has improved symptoms.

The combination treatment is most effective for severe episodes and for severe, long-lasting depression. This approach harnesses the advantages of both methods – fast medication effects and improved understanding of symptoms and life management.

For individuals with moderately severe depression (2 main symptoms and 3-4 additional symptoms), either psychotherapy or antidepressant treatment is suitable.

In cases of severe depression (3 main symptoms and at least 4 additional symptoms) or prolonged illness, a combination of psychotherapy and antidepressants is usually prudent. If symptoms persist or worsen, or if suicidal thoughts arise, hospitalization may be necessary. In inpatient settings, combination treatment should be initiated from the beginning.

Recommendations for Long-Term Treatment of Depression

Unipolar Major Depressive Disorder (MDD) often follows a recurrent and persistent course, posing significant challenges. Maintenance or prophylactic treatment aims to achieve three primary objectives: prevent depressive episode recurrence, reduce the risk of suicide, and mitigate the development of chronicity.

To implement effective maintenance-phase treatment, clinicians must consider each patient’s unique illness trajectory and treatment history. A key recommendation is the continuation of successful treatment for 6 to 9 months following the remission of an acute depressive episode.

While no definitive timeline exists for prophylactic therapy beyond this initial period, it becomes essential in high-risk situations. For individuals who have experienced three or more major depression episodes or have a history of frequent recurrence (e.g., two episodes within 5 years), longer-term maintenance therapy is warranted.

Several adverse prognostic indicators can predict recurrence, including residual symptoms at remission, prior longer episodes, chronicity, severe past episodes, early-onset depression, concurrent dysthymic disorder (referred to as “double depression”), relapse after medication withdrawal, recent episodes, comorbid substance abuse or anxiety disorders, and a family history of MDD in first-degree relatives.

Types of Depression

The types and symptoms of depressive disorders vary. Psychiatrists use the diagnostic procedures’ guidelines to help identify a particular type of depressive disorder. The guidelines specify criteria such as anxious distress, mixed features, melancholic features, atypical features, psychotic features, catatonia, peripartum onset, and seasonal patterns.

The description “Clinical Depression” is not a proper psychiatric diagnosis. The term is used for depression with more severe symptoms which require treatment.

Endogenous versus Reactive Depression

The category “endogenous” or “reactive” depression has been used in the ICD 9 diagnostic manual. Depression can have internal (endogenous) or external (reactive) causes.

Endogenous depression refers to a type of depression that has no apparent external cause such as stress, trauma, or grief. This suggests that genetic or biological factors are the main root cause for this type of depression. Unexpectedly, people who are successful, live active lives, have intact families, and have no obvious reasons for being sad become depressed. This type responds well to the treatment with medication.

External circumstances can cause the onset of depression, called “reactive depression.” The triggering factors might be social isolation, hostile environments, personal losses, or personal misgivings. The symptoms caused by the reactive depression usually disappear after solving the external problems.

Determining the cause of depression is always difficult. Depression can develop at any age, with or without major external events. Therefore, in ICD 10, the diagnosis is based on descriptive characteristics (mild, moderat, sever episodes), taking in consideration the multi multifactoriafactorial cause of depression.

Major Depressive Disorder (MDD)

Major Depressive Disorder (MDD) is the most prevalent form of depressive disorders. A hallmark of a depressive episode is the persistence of depressive symptoms for at least two weeks. The core features of the depressive syndrome include a low, sad, or depressive mood and a loss of joy and interest in almost all activities that typically bring pleasure.

Peripartum Depression (Former Postpartum Depression)

Pregnancy and the period after delivery is a particularly vulnerable time for women. During this time mothers are exposed to major biological, emotional, and social changes causing high risk for developing depression or anxiety.

The change from DSM-4 “postpartum depression” to DSM-5’s “peripartum depression” reflects evidence that around half of depressive episodes related to pregnancy actually occur prior to delivery.

The term “perinatal” refers to the period before and after the birth of a child. Perinatal depression includes depression that begins during pregnancy, called prenatal depression, and depression that begins after the delivery, called postpartum depression.

Catatonic Depression

Catatonic depression, is a combination of catatonia and depression. The condition is categorized under the DSM-5 as Major Depressive Disorder with Catatonic Features.

Catatonia

Catatonia is characterized by severe motor disturbances, such as rigidity and withdrawal. During catatonic episodes, individuals exhibit immobility and mutism, along with stupor.

Catatonia is relatively common in psychiatric conditions, but its occurrence in major depressive disorder is rare. It is predominantly associated with bipolar depression. Bipolar disorder is the most frequently observed psychiatric condition associated with symptoms of catatonia, followed by schizophrenia.

Atypical Depression

is a sub-type of Major Depressive Disorder with atypical features. The main characteristic is the emotional reactivity with moods reacting strongly to environmental circumstances. The individuals suffering of atypical depression feel extremely sensitive. They experience profound fatigue, crave for food and face interpersonal difficulties. The patients feel leaden heaviness in arms or legs.

Unlike classic melancholic depression, atypical depression lacks features like insomnia, weight loss, and loss of reactivity of mood. The positive events don’t have any mood enhancing effect. Increased appetite can be observed through a noticeable increase in food intake or weight gain. Hypersomnia may manifest as either an extended period of nighttime sleep or daytime napping.

Unlike other atypical features, pathological sensitivity to perceived interpersonal rejection is a trait that emerges early and persists throughout most of adult life. Rejection sensitivity occurs both during and outside of depressive periods, though it may worsen during depressive episodes.

Dysthymia

Dysthymia is the old term describing conditions with chronic depressive mood lasting for several years. The symptoms of dysthymia are not severe or persistent enough to meet the criteria for major, moderate, or mild recurrent depressive disorder. In DSM 5 the old diagnosis chronic depressive disorder and dysthymic disorder have ben unified under one diagnosis called “Persistent Depressive Disorder” (PDD).

Individuals with dysthymia feel low, unmotivated, and inadequate on most days. They tend to doubt themselves and feel inferior. They rarely feel happy experiencing non-specific physical symptoms such as fatigue, sleep disturbances, loss of appetite, or headaches. Even minor tasks are exhausting. Despite the difficulties, individuals with dysthymia can generally manage their daily lives.

Agitated or Anxious Depression

This type of depression involves worry, restlessness and anger. It can be easily mistaken for anxiety disorder. People with agitated depression usually do not feel depressed in the sense of feeling fatigued. They experience psychomotor restlessness. The affected individual might move around, feel angry, talk constantly, having shaky hands and racing thoughts. While being externally hyperactive, on the inside they feel confused and helpless.

Seasonal Depression

The symptoms of seasonal depression are different from MDD that occurs year-round. They are less severe. This type occurs only in the dark part of the year, typically in winter. This form has similar diagnostic criteria to MDD, with two differences: in typical depression, there is a loss of appetite, and the sufferer loses weight. In winter depression, the opposite happens: there is increased appetite and weight gain.

The other difference is in sleep: both forms can cause sleep disturbances, but in typical depression, the sleep is deprived (problems to fall and to maintain sleep), whereas in winter depression, people tend to sleep too much. Nonetheless, most depressions in winter are not winter depressions. The seasonal depression is very rare with prevalence in the general population of about one to two percent.

Masked Depression

A Masked (hidden) depression isn’t used as a diagnosis anymore, but some psychiatrist still use the term to describe reduced wellbeing with mostly physical symptoms without obvious depressive symptoms. The symptoms can only be identified on closer inspection. The focus is on physical symptoms of psychogenic (emotional) origin. Psychogenic pain appears real to those affected. Pain can occur in any part of the body. Patients may experience this as back pain, skin tingling, migraines, persistent headaches, chest pain, abdominal pain, etc.

Organic Depression

This type of depression is the result of a physical illness. Some physical illnesses, such as hypothyroidism, diabetes or certain neurological disorders can cause depression. Evaluation by an experienced psychiatrist and thorough examination are critical for diagnostic differentiation and effective treatment.

Major Depressive Disorder (MDD)

Very often people take for granted that they can naturally maintain good mental health. Sometimes they feel sad during certain periods of time. However, it is important to understand though when the symptoms cross the line into Major Depressive Disorder (MDD).

MDD is a pervasive and often misunderstood condition that can manifest with a wide range of symptoms.

Typically, Major Depressive Disorder starts relatively mildly. Initially, individuals may only complain of symptoms such as various physical complaints and a general decrease in performance.

Fully developed MDD is always associated with a profound sadness, sleep disturbances, loss of appetite, a pervasive sense of apathy, a loss of interest, or an inability to make and execute everyday decisions.

As a result, individual’s overall lifestyle and quality of life can be significantly impaired. MDD can persist for weeks, months, and even years, depending on the clinical picture and severity.

Categorizing Major Depressive Disorder

Medical specialists determine the severity based on well-defined parameters. Recognizing the various forms and degrees of depression is crucial for appropriate diagnosis and treatment. Tailoring interventions to the specific intensity, duration and type of the condition can greatly enhance the well-being and chance of full recovery.

Category based on varying levels of intensity

MDD manifests in various forms and varying levels of intensity. Clinically, there are three distinct severity levels of depressive disorders: mild, moderate and severe depressive episodes.

Categor base on course of the Illness

Furthermore, doctors categorize depression and its extent based on the course of the illness. Thus, these conditions can be classified into three different timeframes:

• single depressive episode
• recurring depressive disorder
• long-lasting (chronic) depressive disorder

Criterion of Life Situation

In addition to the temporal course, different life situations must also be considered. An example is seasonal depressive disorder, which predominantly occurs in the autumn and winter months and is referred to as seasonal affective disorder.

Furthermore, depression often occurs in women immediately after childbirth, during the postpartum period, or during pregnancy. The suffering experienced by affected women is significantly high in these cases.

Signs and Symptoms of Major Depressive Disorder (MDD)

Major Depressive Disorder, called also “major depression” has profound effect on people’s ability to function normally. Affected individuals feel “pressed down” in their mood and vitality not being able to master their daily routine.

Psychiatrists count depression to the category of “affective disorders” because it affects how you think and feel. Depression influences emotions and energy levels. Other associated symptoms are sleeplessness, underlying anxiety, sometimes even delusions. MDD frequently appears in phases, called episodes, which continue for weeks or months, sometimes for years.

The first step in recognizing the signs and symptoms of clinical depression is a detailed psychiatric investigation consisting of a patient interview and physical examination. Psychiatrists will recommend laboratory tests, and in more severe cases, an EEG and MRI to rule out underlying physical disorders. Your psychiatrist will prescribe the medication best suited for you and your condition. The best medication is medication that alleviates your symptoms and does not have side effects. The goal of psychiatric treatment of depression is to achieve a full recovery, which means that the depression is cured, and a relapse prevented.

Diagnostics of Major Depressive Disorder

A diagnosis of depression is based on the signs and symptoms developed by the patient. Typical symptoms are low mood, fatigue, loss of appetite and sleeplessness. In severe cases, patients suffer from loss of affect (feelings and emotions) and experience slowdown of thinking (brain fog). In such state, the patient is not able to feel happy or sad but feels “numb”.

DSM 5 Criteria of MDD

The current classification systems DSM 5 and ICD 10 , categorize depression based on the severity of the symptoms and codes them as mild, moderate, or severe. The phenomenological description based on description and quantification of symptoms do not tell us nothing about the underlying root causes.

The second key step in the diagnostic procedure is identifying the frequency of episodes (single or recurrent episodes) and the presence or absence of delusional symptoms.

• Depressed mood, most of the day, nearly every day, can be irritable mood.
• Loss of interest/pleasure: markedly diminished interest/pleasure in all (or almost all) activities.
• Weight loss or gain: significant weight loss or gain or decrease or increase in appetite nearly every day.
• Insomnia or hypersomnia: nearly every day.
• Psychomotor agitation or retardation: nearly every day.
• Fatigue or loss of energy, nearly every day.
• Feeling worthless or excessive/inappropriate guilt: nearly every day.
• Decreased concentration: nearly every day.
• Thoughts of death/suicide: recurrent thoughts of death or recurrent suicidal ideation

Additional required criteria: must have all 4, plus ≥5 depressive symptoms above and the symptoms cause clinically significant distress in social, occupational, or other important areas of functioning.

Social Impact of Major Depressive Disorder

Depression leads to mental and physical inhibition (mental block) that impairs a patient’s social and occupational functioning. In consequence, depressed people are often unable to carry out even the simplest daily activities. They cannot keep their apartment clean or maintain personal hygiene. Other symptoms include feelings of helplessness and social self-isolation. Patients with depression often experience decreased or complete lack of sexual interest (loss of libido) leading to problems in their marital life.

Sense of Guilt and Inferiority

The main themes of depression relate to the person’s ‘spiritual salvation’, material and health condition. The person might believe to be the greatest sinner (guilt delusion), or he might claim to be utterly poor despite his good financial situation (poverty delusion). Patients overestimate negative events. Pleasant experiences have no effect. Depressed people tend to feel guilty and inferior to others.

Social Withdrawal

A common symptom of MDD is social withdrawal with involuntarily and significantly reduced of regular social contacts.

Whether the lack of social interactions is externally imposed or stems from internal inhibitions is irrelevant. Initially avoiding situations like large gatherings can lead to a spiral towards complete social isolation. Thus, social avoidance can not only be a symptom of a depression but also can trigger it. For instance, there is a significantly higher prevalence of depressive symptoms among adolescents who reported having no close friends.

The approach to overcoming social isolation depends on the reasons behind its occurrence, which often involve a combination of factors. The lack of contacts can have far-reaching consequences. In many cases, psychotherapy is the preferred method to stop the vicious circle by addressing underlying emotional issues.

Social Stigma

When family and friends are not familiar with depression, they might seriously underestimate what a depressed person is going through. Very often, a family member will think they are observing someone being lazy, angry and negative. Well-meant advice for a quick pick-me-up only makes depressed people feel worse, because simple remedies that work with sadness will not work for the patient. It is very important for us to understand that clinical depression is a condition that needs appropriate, professional attention and treatment.

Steps in Diagnosing Major Depressive Disorder (MDD)

Depression isn’t a disorder that you can treat on your own; it’s a serious condition triggered by multiple factors. Therefore, the condition must be diagnosed and treated by an experienced psychiatrists and follow standardized procedures. In consequence, the treatment of depression at CHMC adheres to the international standard following a number of steps.

Anamnesis

Anamnesis means a medical history review. The psychiatrist asks you about your personal and family medical history. The reason is to identify possible genetic or environmental factors causing the depression.

In the second step, your psychiatrist will assess the symptoms by asking for their quality, quantity, and duration. These symptoms may include persistent sadness, empty mood, loss of energy, fatigue, sleeplessness, and feelings of guilt.

Physical Exam

The psychiatric exam consists of general physical exam and neurological exam which are critical component of the evaluation process. The objective of the exams is the exclusion of physical illnesses, for example neurological problems on the central nervous system, which might be associated with depression.

Laboratory Test

Laboratory tests are necessary to detect possible health problems before starting treatment. They also serve as a benchmark for later controls to rule out the side effects of the prescribed medication.

Electrocardiogram (ECG)

Similarly, the ECG has the objective of excluding problems on your heart before commencing the treatment and creating a point of reference for the follow-up controls.

Psychological evaluation

Additionally, a psychological evaluation may be necessary in some cases to secure a diagnosis and gain further insight into your psychological status. This evaluation can involve the use of standardized interviews or psychometric tests.

Dysthymia or Persistent Depressive Disorder (PDD)

The old term “Dysthymia” called in the new nomenclature “Persistent Depressive Disorder” (PDD), is a form of long-lasting depression. It has similar symptoms as the clinical depression (Major Depressive Disorder (MDD), but their last longer.

Despite the less severe symptoms compared to Major Depressive Disorder dysthymia may have even more debilitating effect on the individual’s life.

In DSM-5 the diagnosis “Dysthymia” has been replaced with the diagnosis “Persistent Depressive Disorder”. This term comprises the former diagnosis of Chronic Major Depressive Disorder and the old diagnosis “Dysthymic Disorder”. The common diagnosis for both entities has been created due to no significant differences between the two conditions.

Symptoms of dysthymia

Since dysthymia is a chronic disorder, individuals may experience symptoms for years before receiving a diagnosis. They tend not to discuss their symptoms with doctors, believing that it’s part of their character. The condition is characterized by an extended period of depressed mood and at least two additional symptoms, such as insomnia or fatigue. Individuals may also experience low self-esteem, feeling hopelessness and easy irritable. The patients can also have difficulty concentrating or making decisions.

Mild dysthymia may cause people to withdraw from stressful situations, while more severe cases may result in a withdrawal from daily activities and a lack of enjoyment in daily life.

Diagnosing dysthymia

Making the diagnosis for dysthymia can be challenging due to the subtle nature of symptoms. Secondly the patients may hide the symptoms in social situations, making it difficult for others to detect them. The other diagnostic problem is that dysthymia often occurs alongside other psychiatric disorders. often overlapping its symptoms. Comorbid with dysthymia are such psychiatric disorders as panic disorder, generalised anxiety disorder, alcohol and substance use disorders, PTSD, bipolar disorder, and personality disorders.

Suicidal behaviour is also a particular problem for those with dysthymia, making early diagnosis and treatment critical. Persistent Depressive Disorder can have long-lasting effects on an individual’s life, leading to isolation and a decreased quality of life.

DSM 5 criteria for dysthymia

The criteria for persistent depressive disorder (dysthymia) include:

• Depressed mood for most of the day, for more days than not, for at least two years (one year for children and adolescents).
• Presence of two or more of the following symptoms
• Poor appetite or overeating
• Insomnia or hypersomnia
• Low energy and low self-esteem
• Poor concentration or difficulty making decisions
• Feelings of hopelessness
• During the two-year period (one year for children and adolescents), the individual has never been without the above symptoms for more than two months at a time.
• The illness causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
• The symptoms are not due to a substance or medical condition, nor are they better explained by another mental disorder.

It is important to note that the DSM-5 criteria for dysthymia have replaced the previous DSM-IV criteria, which referred to dysthymia as a different disorder. In the DSM-5, persistent depressive disorder encompasses both chronic major depressive disorder and the previous dysthymic disorder.

Causes of dysthymia

We are not able to clearly identify the root causes of dysthymia. However, evidence suggests a genetic predisposition, with depression occurring in up to fifty percent of families with early onset of the symptoms. Other factors linked to dysthymia include stress, social isolation, and lack of social support. In a study using identical and fraternal twins, results indicated a stronger likelihood of both identical twins having depression than fraternal twins, suggesting that heredity plays a role in the development of dysthymia.

Treatment for dysthymia

While the exact cause of dysthymia remains unknown, early diagnosis and treatment can help manage symptoms and improve overall quality of life. It is vital to seek medical attention if experiencing symptoms of dysthymia. The outcome of treatment of dysthymia is lower than for the acute form of depression and tends to last longer. The best results can be achieved by the combination of pharmacotherapy and psychotherapy.

Treatment of dysthymia with psychotherapy

Psychotherapy is one of the treatment options. In fact, cognitive-behavioral therapy (CBT) is the most studied type of therapy. Psychodynamic psychotherapy has been used to treat PDD, but there is a lack of empirical evidence for their effectiveness.

While psychotherapy alone can be effective, pharmacotherapy is generally more effective in direct comparisons. However, a combination of psychotherapy and medication is proved to be the most effective approach. Ultimately, the choice of treatment depends on the individuals and their specific needs, as well as the severity of their symptoms.

Treatment of dysthymia with medication

In direct comparison to psychotherapy pharmacotherapy (treatment with medication) turned to be more effective. Antidepressants, specifically SSRIs, are often prescribed as a first-line treatment due to their tolerable nature. The most commonly prescribed antidepressants for dysthymia include escitalopram, citalopram, sertraline, fluoxetine, paroxetine, and fluvoxamine. However, it takes an average 6-8 weeks before the patients feel the therapeutic effects. Patients with dysthymia often need to try different brands of medication before finding one that works for them. In some cases, a combination of different antidepressants with different mechanisms of action may be necessary. In therapy resistent cases using the augmentation with lithium, lamotrigine, or thyroid hormones may be successful.

Combining medication with psychotherapy

It’s important to note that medication alone may not be enough to effectively treat dysthymia. In fact, a combination of medication and psychotherapy may be the most effective approach. While medication can help manage symptoms, therapy can help address underlying issues, creating an insight, and providing coping mechanisms. However, finding the right medication and dosage can take time. The second challenge can be the treatment resistance due to dysthymia’s chronic nature. Therefore, it’s crucial to work with an experienced psychiatrist to ensure the proper choice of medication and to avoid potential side effects.

Catatonic Depression

Catatonic depression, is a combination of catatonia and depression. The condition is categorized under the DSM-5 as Major Depressive Disorder with Catatonic Features.

What is catatonia?

The term “catatonia” was first mentioned by Ludwig Karlbaum in 1874. It is characterised by a group of psychological, motor, behavioural, and autonomic symptoms.

Older authors like Emil Kraepelin and Karl Leonhard strictly linked catatonia to schizophrenia. However, in recent times, it’s postulated that catatonic phenomena can occur independently of schizophrenic psychoses and are not specific to schizophrenia. High associations with catatonic phenomena have been found in conditions like manic-depressive mixed states. Some authors refer to it as a catatonic syndrome.

According to ICD-10 criteria, the basis of contemporary WHA psychiatric diagnosis, these disorders are characterized by a clinical picture including stupor, psychomotor agitation, postural stereotypes, negativism, catalepsy, varying flexibility, and other symptoms like command automatism and speech stereotypes. In the pre-antipsychotic era, a significant portion of catatonic patients died due to complications like exhaustion, severe malnutrition, or self-harm. Nowadays, antipsychotic drugs and advancements in non-pharmacological psychiatric therapies offer treatment options with high response rates.

In the malignant form, known as pernicious catatonia, besides the mentioned catatonic symptoms, there is autonomic dysregulation with no detectable infection, characterized by high fever, circulatory disturbances, dehydration, and other functional impairments. Elevated creatine kinase levels are also observed.

Differential diagnosis should consider organically induced catatonic disorders and drug-induced catatonic phenomena, along with other diagnoses in the psychiatric spectrum like affective psychoses, neurological, and metabolic disorders. Drug-induced psychotic disorders can also present with catatonic phenomena.

Symptoms of Catatonia

Catatonia is characterized by severe motor disturbances, such as rigidity and withdrawal. During catatonic episodes, individuals exhibit grimacing or refusal to eat. Immobility and mutism are the most prevalent symptoms, along with stupor, a state of dulled consciousness. Other characteristics of catatonia are:

• Posturing and catalepsy, where someone maintains a position, are more severe manifestations of catatonia.
• Stereotypies, repetitive and purposeless movements, are also observed, like rocking back and forth.
• Echolalia involves repeating words spoken by others, while echopraxia mimics their movements.
• Mannerism refers to performing exaggerated or odd actions instead of typical ones, such as hopping instead of walking.
• Waxy flexibility, when resistance is followed by maintaining a manipulated body part’s position.

Catatonia is relatively common in psychiatric conditions, but its occurrence in major depressive disorder is rare. It is predominantly associated with bipolar depression. Bipolar disorder is the most frequently observed psychiatric condition associated with symptoms of catatonia, followed by schizophrenia.

Causes of Catatonic Depression

The causes of catatonia remain unclear, but several theories have been proposed. These include deficiencies in gamma-aminobutyric acid (GABA), dysregulation in glutamate and dopamine, as well as abnormalities in thalamic and frontal lobe metabolism.

The evolutionary theory suggests that catatonia may stem from an exaggerated primal fear response. Prehistoric ancestors, constantly facing predators, may have developed the ability to remain motionless for extended periods to avoid detection. Biologists observe catatonia by animals exposed to life threatening situations.

Treatment of Catatonic Depression

Catatonic depression requires a combination of treatments for both depression and catatonia. Given the potential life-threatening complications caused by catatonia, prompt intervention is crucial.

Benzodiazepines and electroconvulsive therapy (ECT) are the primary treatments for catatonia, with additional use of certain atypical antipsychotics and additionally antidepressants in the later stage.

Benzodiazepines, particularly Lorazepam, are the preferred choice, offering rapid relief from catatonic symptoms including associated anxiety and sleeplessness. They can be administered intravenously, through injections, or in tablet form.

In treatment-resistant cases, electroconvulsive therapy (ECT) is the method of choice, especially for malignant catatonia.

Depression in Neurological Disorders

Depression is a complex mental health condition that can manifest in various forms and often co-occurs with other neurological conditions. Despite remarkable successes in treatment of depression associated with neurological disorders, there is further need for research. Only a better understanding of the underlying mechanisms of such comorbidities will facilitate development of more effective treatment methods.

Depression in Alzheimer’s Disease

Depression is a common comorbidity in patients with Alzheimer’s Dementia (AD), with prevalence rates reaching up to 50%. Moreover, research suggests that depression may act as a risk factor for the development of cognitive impairments or dementia later in life.

One potential link between depression and dementia lies in the observation that depression can contribute to hippocampal atrophy. Conversely, depression ranks as the third most common psychiatric symptom in Alzheimer’s Dementia, following apathy and psychotic symptoms. High rates of depression comorbidity also corelates with fronto-temporal dementias and Lewy Body dementia.

The neuropsychological assessment for distinguishing depression from dementia is challenging during the acute phase of depression. Making accurate differential diagnosis is possible first after severe depression subsides. These diagnostic tests are comprehensive, evaluating verbal episodic and non-episodic memory, executive functions, attention, language, visual processing, and processing speed.

Depression in Parkinson’s Disease

In functional imaging studies, depressed patients with Parkinson’s Disease exhibit significantly reduced metabolic activity in limbic areas and the basal ganglia. Similar to Alzheimer’s Disease, prior depressive episodes may elevate the risk of developing Parkinson’s dementia.

It is crucial to exercise caution when selecting antidepressant treatments for these patients, as they often respond with blood pressure and motor side effects.

Huntington’s Chorea and Depression

Depression is also highly prevalent in Huntington’s Chorea, with reported rates of up to 75%.

Depression in Multiple Sclerosis (MS)

Multiple Sclerosis (MS) is frequently comorbid with depression., with a prevalence ranging from 25% to 50% of MS patients suffer of depression. Multiple sclerosis patients often display poor therapy adherence and a high propensity for suicidal ideation. However, also the immunomodulatory medications used in MS treatment also has a depression-triggering effect.

Amyotrophic Lateral Sclerosis (ALS) and Depression

Depression’s occurrence is also frequent in in Amyotrophic Lateral Sclerosis (ALS). The diagnosis of depression in ALS is difficult because of the overlapping symptoms like anorexia, insomnia, or fatigue, occurring independently of depression. Whether the prevalent depression in supranuclear gaze palsy or corticobasal syndrome represents prodromal syndromes remains uncertain.

Vascular Depression (Subcortical Ischemic Depression)

The concept of vascular depression emerged in the late 1990s, defining it as a cerebrovascular condition that predisposes, causes, or sustains depression in older individuals. The late-life depression and cerebrovascular changes are intertwined. The genesis of cerebrovascular depression depends on the extent and distribution of vascular damage of affected networks.

The pathologies in fronto-striatal and fronto-limbic connections also contribute to depression. Clinical presentation primarily includes executive function problems, psychomotor retardation/inhibition, and apathy. Cognitive deficits take centre stage, and affected individuals are often unaware of their illness and exhibit suspicion.

Besides executive dysfunction, these patients may struggle with visual naming difficulties and reduced verbal fluency. There is an increased risk of treatment resistance, incomplete remission, and dementia development.

Imaging changes are detectable as hyperintensities in the subcortical white matter, reflecting the organic basis of vascular depression. The severity of depression often correlates with the extent, location, and volume of these defects, with temporal and frontal lesions most strongly associated with depression.

Depression and Substance Use Disorders

There is a high comorbidity between depression and substance use disorders, especially among older individuals.

Alcohol Use and Depression

Notably, alcohol dependence is significantly higher among older depressed patients compared to non-depressed counterparts. This comorbidity is associated with a high risk of suicide, with around 60% increase compared to depressed individuals without alcohol issues.

Opiat/Opioids Use and Depression

Depression is also common among those with opiat/opioid dependence, often accompanied by anxiety and personality changes. This comorbidity is particularly evident in patients with chronic pain syndromes. Moreover, the number of individuals aged 65 and older who consume opioids doubled in Western countries due to the COVID pandemic and socio-economical changes.

Misuse of Stimulants and Depression

In younger patients, high comorbidity between depression and anxiety correlates with dependence from stimulants such as cocaine, amphetamine and methamphetamine.

Tobacco Dependence and Depression

In the case of nicotine dependence, withdrawal is associated with an increased risk of depression, whereas sustained smoking cessation is linked to a significant reduction in depressive symptoms.

Depression and Personality Changes in Elderly Patients

Research on the comorbidity of depression and personality disorders in older patients is limited. However, some studies have reported prevalence rates as high as 24%. The presence of a personality disorder is often associated with an early onset of depression. Certain personality traits, such as avoidance, dependency, and perfectionism, are considered risk factors for this comorbidity. These traits can lead to greater loss of independence and delayed therapeutic success. On the other hand, positive coping strategies, self-efficacy, and social competence are protective factors.

Depression and Pain

A shared pathogenic basis for depression and pain was postulated in the 1990s. Biogenic amines, serotonin, and norepinephrine appear to play a significant role in the development of comorbid symptoms. The lifetime prevalence of pain in depressive patients averages 65%, with chronic pain, particularly in the head, abdomen, joints, and chest, being strongly associated with depression. This comorbidity is more common among women.

Depression and Neurological Disorders Caused by Cardiovascular Diseases

A close relationship exists between late-life depression and cardiovascular diseases. This connection appears to be reciprocal: cardiovascular events increase the risk of depression, and depression, in turn, acts as a risk factor for cardiovascular diseases. The risk of ischemic heart disease is increased by 1.5 to 2 times in older individuals with depression. Conversely, approximately 20% of patients experience depression following a myocardial infarction, which, in turn, raises mortality rates in these individuals by 3.5 times in the first six months after the event.

Depressive symptoms lead to a worse disease course, frequent hospitalisations, and reduced benefits from cardiovascular surgeries. Various pathophysiological mechanisms are discussed regarding this comorbidity, including an imbalance between sympathetic hyperactivity and parasympathetic underactivity, reduced heart rate variability, changes in the beta-adrenergic system, and overactivity of the hypothalamic-pituitary-adrenal axis.

Causes of Depression

Depression usually arises from a combination of several factors. The role of genetic and environmental factors varies from person to person. Most models explaining depression are based on genetic predisposition, neurobiological imbalances, and certain developmental and personality factors (psychosocial factors).

People affected by depression generally have a lower tolerance for emotional, physical, and life stressors than healthy individuals. This particular vulnerability plays a significant role in triggering and sustaining depression. Depressive episodes are often triggered by personally distressing events or situations of overwhelm, to which at-risk individuals are more sensitive than others.

Neurobiological Causes

The immense progress in the neurosciences, which started in the mid-20th century, showed that depressed people have in their brain an imbalance of the neurotransmitters. The neurotransmitters allow the nerve cells to communicate with each other. The neurotransmitters can be influenced by variety of factors, such as genetics, social circumstances, or physical illnesses. Treatment with anti-depressants helps to restore the balance of neurotransmitters and as its effect to remove the symptoms of depression.

Genetic Influences

A large body of evidence from family and twin studies points to genetic contributions for causing depression. The twin studies compare disease frequencies in identical twins. Only half of the identical twins gets ill if the sibling developed depression. It means that other factors than genetics contribute to the onset of depression in the second half. The family history puts their offspring at an increased risk of depression. As a result, a child with one depressed parent is 10-15% more likely to develop depression than the average. If both parents suffer of depression, the risk for their children increases to 20-40%. Such results prove the multi-factorial genesis of depression.

The exploration of numerous genes and their influence on depression didn’t show one particular gene causing the illness. This means that an interaction of several genes is necessary to trigger the onset of depression. So even the genetic component of depression requires synchronized action of various genes.

Psychosocial Causes of Depression

Many studies have confirmed that among the psychosocial factors, stressful severe life events, such as breakups, loss of a loved one, or job loss, are likely to contribute to the onset of depression.

Wang et al. (2016) highlight that socioeconomic status, and the severity of depression are negatively related. The scientists claim that a fourfold increased risk of depression is the attribute of sexually or physically abused women in childhood compared with women without such experiences.

Certain physical illnesses (e.g., thyroid disorders), medications (e.g., birth control pills, antibiotics), or substance abuse can trigger depression.

In addition, the attachment theory of Bowlby (1977) claims that disrupted affectional bonds between children and caregivers have been the key contributors to psychopathology, including depression and anxiety.

Similarly, the developmental pathway from early conduct problems to adult depression explains another possible cause of depression.

Environmental Effects

Converging evidence indicates that environmental exposures can contribute to the onset of depression. Air pollution, use of herbicides, food preservatives and other chemicals in every area of urban life can affect the activity of certain brain cells (i.e. serotonergic and dopaminergic neurons.)

Cultural Background and Depression

The cultural factors may influence symptoms of depression. For instance, in some cultural contexts, mental distress is primarily expressed through physical symptoms. This can sometimes make it challenging for doctors and psychologists to identify depression. Therefore, while diagnosing depression it’s essential to consider culture-specific factors and its nuances.

Frequency, Ethnic and Gender Differences

• This condition occurs in people of all cultures, all social classes, and nationalities
• Race or an ethnic origin has no influence on the development of depression.
• Currently, there are mathematically 340 million cases of depression existing worldwide.
• While approximately 25% of adult women develop depression only about 10 % of all men affected.
• 20% of all Germans develop depression once in their life. Worldwide figures vary between 8-20%.
• The average age of manifestation of a depressive disorder lies between the ages of 20 – 40.

Chemical Imbalance in Depression

It is a common belief that depression is a result of a simple chemical imbalance. However, this oversimplified idea does not capture the true complexity of this mental health condition. Research suggests that the cause of depression cannot simply be explained by an excess of lack of specific brain chemical. Instead, a mix of factors plays a role—things like disrupted mood regulation, genetic predisposition, and the effects of challenging life experiences. The belief is that these factors interact, paving the way for the onset of depression.

The Complex Dance of Neurotransmitters

While neurotransmitters play a role, it is far from a straightforward equation of one being too low and another too high. Numerous neurotransmitters (serotonin, noradrenaline, dopamin, glutamate, melatonin, and more) are at play, orchestrating intricate reactions both inside and outside nerve cells. These millions, even billions, of chemical interactions form a dynamic system shaping our mood, perceptions, and overall life experience. The complexity of this system becomes apparent when considering two individuals with similar depressive symptoms. While having similar depressive symptoms, the effectiveness of treatments may vary significantly because of distinct internal and external challenges.

Scientists have made progress in understanding the biology of depression, but there is still a lot unknown. Significant breakthroughs include identifying specific brain regions related to depression, the role of neurotransmitters and exploring how genetics and lifestyle influence the risk and symptoms of depression.

Deciphering the Brain’s Influence on Mood

From Heart to Brain: Tracking Emotions

Contrary to popular lore attributing emotions to the heart, science unequivocally establishes the brain as the seat of emotions. Specific brain areas regulate mood, with researchers emphasizing that nerve cell connections, growth, and circuit functioning hold more significance than the levels of individual brain chemicals.

Technological Marvels: Peering into the Brain

Brain imaging technologies, including PET, SPECT, and fMRI, provide insights into the working brain. These tools help to see how different brain regions regulate mood and how depression affects various functions, such as emotions and neurocognitive functions. Key players in this neurological drama include the amygdala, thalamus, and hippocampus.

Unraveling the Neurological Maze: Amygdala, Basal Ganglia, and Hippocampus

Amygdala: Emotional Epicenter

The amygdala, nestled deep in the brain, governs emotions like anger, pleasure, and fear. Activation during emotionally charged memories, such as frightening situations, persists in individuals with sadness or clinical depression. This prolonged activity may contribute to the amygdala’s enlargement.

Basal Ganglia: Underneath the Surface

The basal ganglia, linked to movement and emotional processing, resides deep within the brain. Interactions with structures closer to the brain’s surface may influence functions like memorization and thinking. Studies hint at structural changes, including shrinkage, in the basal ganglia of individuals struggling with depression.

Hippocampus: Memory and Beyond

Essential for retaining long-term memories, the hippocampus collaborates closely with the amygdala. In people experiencing depression, the hippocampus tends to be smaller, possibly because stress hormones impede the growth of neurons.

The Link Between Antidepressants and Neurogenesis

Delayed Relief: Unraveling Antidepressant Mysteries

Antidepressants, designed to boost neurotransmitter levels, confound experts with their delayed onset of mood improvement. The effect of antidepressants seems to be more complex than the popular believe, that they just increase the concentration of the neurotransmiters in the synaptic space. The recent research suggests that true mood improvement might arise as nerves grow, forming new connections, a process taking weeks. Animal studies support the theory that antidepressants stimulate neurogenesis, promoting the growth and branching of nerve cells in the hippocampus.

Promising Path: Targeting Neurogenesis for Quicker Results

If the real value of antidepressants lies in generating new neurons, strengthening nerve connections, and enhancing information exchange between nerve circuits, a new era of depression medications could emerge. Tailoring treatments to specifically promote neurogenesis offers hope for quicker results compared to current approaches.

Multifaceted Interplay between Chemical Imbalance and Depression

Holistic Understanding for Targeted Treatments

The origins of depression transcend the simplistic narrative of a chemical imbalance. Advances in neuroscience reveal complex connections between brain regions, neurotransmitters, and genetic factors. This comprehensive understanding paves the way for targeted treatments, providing hope for more effective and swifter relief from the clutches of this pervasive mental health condition.

History of depression

Melancholy, now called depression, has accompanied humans since the beginning of history. Its symptoms found their resonance in art, literature, and philosophy, which tried to interpret, explain and to cope with the mental despair.

In the following chapters, we shed light on how the understanding of the condition evolved over the past millennia.

Ancient Egypt

The ancient Egyptian document, known as the Ebers papyrus, from circa 1550 BC, contains the first description of depression. Some notes in this papyrus describe a status of disordered concentration and emotional distress of the mind. Such symptoms are typical for depression.

Ancient Greece

The foundation for the modern medicine has been created in ancient Greece. In the 4th and 5th centuries B.C.E., the Greek philosopher and the father of modern medicine, Hippocrates separated medicine from religion crating, what we call today an “evidence based” science.

The term “melancholia”, the older description of today’s depression, derives from the Ancient Greek words “melas” (black) and “kholé” (bile). Hippocrates argued that mental illnesses have biological origins. His viewpoint contradicted the popular custom of attributing mental health disorders to supernatural or magical sources. He described “melancholia” as a manifestation of a brain dysfunction.

Humoral hypothesis

According to the humoral hypothesis, humans needed a balance of four “humors” (blood, black bile, and yellow bile) and three elements such as fire, water, and earth. Melancholy was understood as an excess of black bile, while mania was believed to be caused by overproduction of yellow bile.

In ancient and later in medieval times, the treatment aimed to restore the balance of humours, using dietary measures, baths, and activities such as movement, music, and stimulating conversations. The ancient physicians also used bloodletting, purgatives, cautery, or medication. These methods were still in used until the end of the early XIX century.

In that time melancholy was considered not only as a disease, but also as a specific human constitution. Its occurrence was related to the logic of the parallelism between microcosm (individual) and macrocosm (nature) with the afternoon, autumn, or higher age to which a melancholic character was assigned.

Plato, the “psychological” hypothesis

The Greek philosopher Plato (427-347 BC) believed that the cause of madness was in the mind. He saw mental illness as the result of a person’s ignorance about his psyche leading to self-deception. Even today the division of psyche and body reflects such past concept, marking the barrier between psychiatry and psychology.

Plato was convinced, of the connection between melancholy and genius: “Why do all exceptional men in philosophy or politics or poetry or the arts prove to be melancholic?” (Phaedrus, c. 360 BC).

Middle Ages

In the Middle Ages retained the humoral pathology approach of the ancient world. However, the humoral theory representing four temperaments, as well as the corresponding diseases, were given a religious meaning. In the philosophy of the Middle Ages earthly life was necessarily connected with illness and suffering, while the true healing could only lie in the resurrection, in the afterlife.

The beginning of modern era

In the modern age, the ancient-medieval views continued, but with the secular orientation towards nature and the individual. This mindset emphasized the glorification of youth, beauty, and health, and the suppression of death. Such perception is exemplified in the painting “The Fountain of Youth” (1546) by Lucas Cranach (1515-1586).

In the modern era, melancholy was increasingly interpreted empirically. The Oxford theologian Robert Burton (1577-1640) derived this mental state from biological, psychological, and socio-cultural conditions. In his “Anatomy of Melancholy” (1621) he wrote:

“Those who have an unfavourable position of the Moon, Saturn, or Mercury in their horoscope; those who live in overly cold or hot climates; those who come from melancholic parents or who have suffered from illness for a long time; people who live a naturally solitary life, wholly given over to contemplative and withdrawn from active life – they are all most susceptible to melancholy. Both genders are affected by it, but when women fall ill, they are far worse and more violently tormented.” 

Reflecting on such statement we must admit, that apart of the astrological admixture, the description of factors causing depression corresponds to the modern view about depression.

Enlightenment

During the Age of Enlightenment, new experiences, theoretical interpretations, and social initiatives emerged. They led physicians to attribute melancholy to the nervous system. The materialistic perspective made them believe that melancholy could be treated with mechanical methods. They used in the treatment of mental illnesses showers, rotational machines, cold and warm stimuli, and chemical means like arsenic, mercury, bloodletting, and enemas. Enlightenment was also the age where the first psychological techniques such as manipulating emotions were introduced.

Enlightenment was also the era with humanistic attempts in medicine and psychiatry. In the field of psychiatry, the patients were liberated from chains through institutional reforms. In France, psychiatrists Philippe Pinel and Jean Etienne Dominique Esquirol, and in Germany, physician Johann Christian Reil were associated with these reforms. 

Metaphysics of suffering

Georg Wilhelm Friedrich Hegel (1770-1831), who dealt with the disturbances and illnesses of the soul in his philosophical system, emphasized the anthropological dimension of melancholy and saw it as a fundamental developmental stage of humans.

The Danish philosopher Søren Kierkegaard (1813-1855) gives melancholy an existential meaning, which shaped psychopathology into the 20th century. He wrote:

“As immediate spirit, human beings are connected to all earthly life, and now the spirit wants to collect itself out of this dispersion and explain itself within itself; personality wants to become aware of itself in its eternal validity. If this does not happen, if the movement is interrupted or pushed back, then melancholy sets in.”

The above philosophical statment refelcts in differnt langage the proces of individuation described by C.G. Jung.

Depression. The evolution of diagnosis

Despite the symptoms of depression are known to humans since millennia, the scientific research on depression started first at the end of the 19th century.

Emil Kraepelin’s, classification

Emil Kraepelin, (15.02.1856 – 07.10.1926) was a German psychiatrist, and founder of modern scientific psychiatry. He was the first who systemized the mood disorders creating for these conditions a term called “manic depression”. This term today would cover a range of mood disorders, such as depression and bipolar disorder.

Sigmund Freud, mourning and melancholia

Sigmund Freud, (06.05.1856 – 23.09.1939) was Austrian neurologist and the founder of the psychodynamic approach in psychology. he developed the first effective psychotherapeutic method for treatment of mental illnesses.

In his essay, “Mourning and Melancholia” (1917) he linked the state of melancholia to mourning. Both conditions are often triggered by the same circumstances. Freud discusses what conditions need to be present for the two states to progress along their varying paths. He theorized that the depressed individual has identified with the object of affection through an unconscious, narcissistic process. He wrote: “Mourning is regularly the reaction to the loss of a loved person or to the loss of some abstraction which had taken the place of one, such as one`s country, liberty, an ideal, and so on.”

Mourning

Mourning is not considered a psychiatric disorder. Morning is a normal reaction accompanied by depressive symptoms to traumatizing events. Over time reality wins out and slowly the person returns to normal state of emotions.

Melancholia

In melancholia the depressive symptoms persist over longer period. Quoting Freud: “In mourning it is the world which has become poor and empty; in melancholia it is the ego (patients’ personality) itself.”

Freud assumed that the melancholic individuals may know that they have lost something. However, the person is not aware of the underlying psychological mechanism. In melancholia essence of the loss is inaccessible to consciousness. So, in mourning the libido (life energy) slowly withdraws from the lost object and replaces it with other one. In contrary in melancholia, the libido withdraws into the Ego and identifies with the lost object.

Karl Abraham, libidinal hatred

Karl Abraham, (03.05.1877 – 25.12.1925) was a German psychoanalyst, and a collaborator of Freud. He also analyzed the relationship between mourning and melancholia. For him, the structure of melancholia was closer to that of obsessive neurosis rooted in the intense hostility toward the outside world. In both illnesses, hostility reduces the ability to love.

Abraham assumed that in melancholia, the hostile drives are projected and suppressed. Based on the Freudian theory he proposed a psychopathological model of depression. Abraham’s idea was, that libidinal hatred projected onto the outside world, reverts back onto the subject. The subject (patient) suppressing the aggressive impulses, develops depressive symptoms. The process of suppression consumes the “libidinal energy” and in consequence the patient develops depressive symptoms.

Depression, contemporary diagnostic

Today’s psychiatric diagnostic is based on the so called phenomenological (descriptive) psychopathology. It examines and describes the basic structures of subjective experience and their modifications in mental illnesses using empirical methodology.

The ICD-10 (International Statistical Classification of Diseases) is a medical coding system developed by the WHO (World Health Organization) which includes criteria for mental and behavioral disorders. ICD 10 is similar to the American statistic manual DSM (Diagnostic and Statistical Manual of Mental Disorders).

Today depression is categorized based on symptoms severity in mild, moderate, and severe episodes. The additional criteria are the presence of additional psychotic symptoms. Such condition is called depression with psychotic features. The second important criteria is the symptoms distribution in time: single episodes or, in case of long-lasting symptoms: recurring depression.

Internal and external factors causing depression

Depression is caused by internal and external factors. The internal factors are the genetic predisposition and changes of the concentration of the neuromodulators in certain brain areas. The external factors are environmental factors and changing live circumstances.

The internal factors respond well to the treatment with medication. However, the external factors can be mastered only by your action. The first step before acting is the understanding the nature of your problems. In the second step you will create the “course of action plan”, helping you to resolve the problems. The difficulties at work or in the partnership can’t be solved in days or weeks. You will need months or even years to find the way out of the crisis.

Relationship with therapist

The prerequisite of a successful psychiatric treatment including the therapy for depression is a trustworthy relationship with your psychiatrist and/or psychologist. You have to be transparent with your healthcare provider reporting honestly about your worries, work and private circumstances, as well as possible side effects of the medication.

Based on your feedback the psychiatrist can adjust your medication. The psychotherapist may change the therapy goals or even refer you to other psychologist who’s training could be a better match for your particular problems. 

Preventing Depression

Depression isn’t a disorder that patients can treat on their own. Depression must be diagnosed and treated by psychiatrists or psychologists. Only mild depressive episodes can be treated with psychotherapy alone. In the more serious cases the most effective treatment of depression consists of medication and psychotherapy. In patients treated only “biologically”, i.e. with medication, the symptoms can appear again despite of using the same dosage of an antidepressant.

There is no warranty how to prevent the onset of depression or how to avoid a depressive relapse. Even during the therapy, peaple might experience drawbacks and periods of sadness. The way to recovery is not linear. However, there are several ways to reduce the risk of a relapse.

The prerequisite of effective therapy is to follow the treatment plan, including regular visits by the psychiatrist and psychologist. Any changes to the medication should be discussed with the psychiatrist. The effect of uncontrolled stopping the medication can be the reappearance of the depression. A sudden discontinuation of the medication can trigger unpleasant physical symptoms (drusiness, nausea) and mood swings. Such symptoms can be avoided if the adjustment, reduction, or discontinuation of the medication happens gradually under the supervision of the psychiatrist.

The knowledge of the nature of depression is also important for the patient’s family and friends. People often think that patients suffering from depression were able to overcome the symptoms using their willpower. Such negative “encouragement” can lead to aggravation of the depressive symptoms. The lack of awareness about the nature of depression by laypeople around can amplify feelings of guilt, worsening a person’s psychological status.

Below few recomendations for patients how to avoid a relapse:

• Don’t expect a “quick fix” of the depression. Be patient with yourself and your recovery process. The process of healing takes time.
• Be careful while judging your progress. Don’t overestimate a temporary improvement. It’s not uncommon to experience setbacks during the recovery process.
• Pay attention to warning signs working with your psychiatrist and psychotherapist to learn what might trigger your depressive symptoms.
• Set realistic goals. Set achievable goals and fragment the process into smaller tasks. Accomplishing your goals will boost your self-esteem and motivation helping to overcome feelings of isolation and hopelessness.
• Be open and honest with your psychiatrist about how do you feel. Report any adverse affects caused by the medication; itcan be replaced by such without side effects.
• Enhance your social network spending time with your loved ones and friends. Talk to them about your problems. Remember that it’s not a sign of weakness to ask for help.
• Participate in the support groups. This helps you to understand the nature of your illness. You will not feel alienate meeting people who share the same problems.
• Take care of your physical fitness. Exercising will help you to lift your mood and reduce symptoms of depression.
• Get enough sleep. The duration of a refreshing sleep should be at least 7 hours.

Avoiding alcohol and recreational drugs

Alcohol and drugs can be used by depressive people giving them a short-term release. However, in the long run they lead to addiction worsening the symptoms and making depression harder to treat. In such situation you will suffer of depression and additionally deal with the demon of addiction.

Integrative Therapy for Depression

Integrative therapy centres around the patient as a whole, using therapies that draw from both evidence-based and experience-based approaches. Integrative medicine shouldn’t be mistaken with alternative medicine, which uses a nonconventional (non-evidence-based) approach.

By blending alternative and conventional Western medical therapies, integrative medicine offers safe and effective treatment that utilizes a variety of disciplines. Unlike alternative medicine, integrative medicine does not replace traditional medical care. Instead, it works hand in hand with the psychiatrists and psychologists.

The integrative medicine for depression follows the holistic approach considering emotional, physical, social, spiritual, and environmental factors that may be contributing to depression. After the initial assessment the integrative medicine practitioner develops a personalized plan based on the immediate health needs. The goal is to address the underlying causes of the illness and facilitating healthy behaviours and self-care skills supporting the psychiatric treatment plan. The practitioner also sends a summary of the visit and recommended therapies to the psychiatrist. The applied remedies and complementary therapies should not interfere with the traditional medication.

Certification in Integrative Medicine

Training and certification in integrative medicine is becoming increasingly popular among healthcare practitioners. In addition to their professional education and accreditation, physicians often pursue certification in this field. Obtaining board certification in integrative medicine requires rigorous training and testing. It ensures that practitioners possess a deep understanding of integrative medicine practices and principles.

Certified integrative medicine practitioners can offer a range of treatment options, such as acupuncture, relaxation technics, and mindfulness-based interventions. By combining conventional and alternative approaches, they can provide comprehensive care that addresses patients’ physical, emotional, and spiritual needs.

Integrative Medicine Professionals

Integrative medicine professionals are mainly medical doctors coming from distinct specialities. The integrative medicine practitioner must be fully accredited by the medical chamber of the country. In the US the training and certification proces are regulated by the American Board of Physician Specialties and in Germany by the German Medical Chamber. The certified practitioners are bound by the Medical Code of Ethics.

Integrative medicine addresses all aspects of a patient’s health, including physical, emotional, social, spiritual, and environmental influences. Practitioners not only treat immediate health concerns but also focus on promoting overall health and well-being. While integrative medicine can be helpful in treating depression, it’s generally not enough on its own. It should be used in conjunction with medication and psychotherapy for optimal results.

Integrative Medicine Technics in Therapy for Depression

Depression is a complex condition that requires a comprehensive treatment plan. Medication and psychotherapy are evidence-based treatments that have been proven effective in managing depression. Alternative techniques can be helpful in alleviating symptoms and promoting overall well-being. However, they should not be used as a substitute for evidence-based treatments. It’s important to work with a healthcare professional to develop a treatment plan addressing all aspects of health and well-being.

Acupuncture

The acupuncture is a traditional Chinese medicine technique that has been used for centuries to treat a wide range of conditions. Acupuncture has gained popularity in recent years as a complementary therapy for various conditions, including chronic pain, anxiety, depression. It could be used also for smoking cessation. It’s often used in conjunction with other treatments, such as medication, physical therapy or psychotherapy, to enhance their effectiveness.

The practice of acupuncture is based on the idea that energy flows through the body along specific pathways called meridians. When this energy flow is disrupted, it can lead to various physical and emotional imbalances. Acupuncture aims to restore the balance of energy flow by stimulating specific points along the meridians.

During an acupuncture session, the practitioner will insert thin, sterile needles into the skin at specific points on the body. The needles may be left in place for several minutes while the patient relaxes. The needles may be manipulated to increase or decrease the flow of energy in the body.

The use of acupuncture is generally considered safe when performed by a licensed practitioner. Side effects may include soreness, bruising, or bleeding at the insertion site.

Relaxation Techniques in Integrative Therapy for Depression

The results of a meta-analysis of nine studies indicates that relaxation techniques are cost-effective, safe, and low risk. Furthermore, it has been found that they can effectively reduce depressive symptoms if practiced daily for more than eight weeks. Additionally, the study concludes that these techniques can be easily taught and used, making them accessible to a broad range of individuals.

The implications of the study for practice are significant. Practitioners can encourage patients to use relaxation techniques as part of their treatment plan for depression. The techniques are simple and do not require any special equipment or changes in lifestyle. Practitioners may recommend these techniques to patients who cannot or do not want to take medication for depression. Finally, the study suggests that relaxation techniques may provide long-lasting benefits for those who practice them regularly.

Autogenic Training

Autogenic training aims to achieve autonomic self-regulation by reducing stimulation and training imagery. It is based on three principles: reduction of stimulation, mental repetition, and passive concentration. The technique’s focus on inner sensations and passive observation allows for a unique and effective approach to stress reduction and relaxation. The technique can be performed in different postures and consists of six exercises, with modifications for specific clinical needs. The exercises involve verbal formulas, focusing on sensations such as heaviness and warmth, as well as cardiac and respiratory activity. New exercises are added gradually, with brief periods of concentration. Autogenic training restores balance between the sympathetic and parasympathetic branches of the autonomic nervous system.

Quantitative reviews suggest that autogenic training is as effective as other bio-behavioral interventions for most psychosomatic disorders. It may specifically decrease heart rate and is claimed to benefit respiratory and circulatory disorders, insomnia, and anxiety. Overall, autogenic training provides a unique and effective approach to inducing relaxation and reducing stress-induced disorders. The technique’s ongoing evolution highlights its continued relevance in the field of mental health and well-being.

History of autogenic training

Johannes Heinrich Schultz was German psychiatrist and psychotherapist. He developed the system of self-hypnosis called autogenic training. Autogenic training induces a relaxation response by visualizing bodily perceptions. The technique has been used to alleviate stress-induced psychosomatic disorders. Biofeedback practitioners have integrated elements of autogenic imagery to aid in thermal biofeedback. Schultz wanted to explore an approach that avoided the passivity of hypnotherapy and developed six basic exercises based on his research on hallucinations in healthy persons.

Progressive Muscle Relaxation (PMR)

American physician Edmund Jacobson experimented with relaxation technics. In the 1920s he developed the progressive muscle relaxation (PMR). In 1929, Jacobson published the book “Progressive Relaxation”, which included a detailed procedure for removing muscular tension. The method involves intentionally tensing and then releasing specific muscle groups to induce relaxation, using both “top-down” and “bottom-up” processing. As the tension is released, attention is directed towards the differences felt during tension and relaxation. This allows the patient to learn to recognize the contrast between the two states.

Progressive Muscle Relaxation (PMR) is based on the observation that muscle tension is a psychological response to anxiety-provoking thoughts, and that muscle relaxation can help alleviate anxiety. PMR has been found to have long-term effects on various aspects of mental health. These effects include a decrease in overall anxiety and in anticipatory anxiety related to phobias. It reduces the frequency and duration of panic attacks and improves the ability to face phobic situations. Further long-term benefits are improved concentration, and increased self-esteem, and increased spontaneity and creativity.

Tai Chi

The origins of Tai Chi stem from Chinese philosophy, specifically Daoist and Confucian thought. Tai Chi philosophy emphasizes working with the flow of yin and yang elements. The practice involves avoiding force against force, instead of using softness and hardness to move. Tai Chi is a low-impact exercise that helps maintain strength, flexibility, and balance. It’s often referred to as “meditation in motion” and has many health benefits. Tai chi is unique because the movements are never forced, the muscles are relaxed, and the joints are not fully extended or bent. It can be easily adapted for anyone, from the most fit to those confined to wheelchairs or recovering from surgery.

Research has demonstrated that depression is associated with structural and functional irregularities in certain brain regions that are responsible for emotion processing, self-representation, reward, and responding to external stimuli such as stress and distress. Tai Chi has been shown to have the potential to modulate these brain regions/networks that are linked to depression. The findings of various studies indicate that Tai Chi improves the psychological well-being, by decreasing levels of stress, anxiety, depression, as well as by increasing self-esteem.

Yoga

Yoga is a practice originating from ancient India with physical, mental, and spiritual components. The practices vary greatly in Hinduism, Buddhism, and modern yoga. The origins of yoga are disputed, with linear and synthesis models. Yoga’s core principles were established in the 5th century CE and developed over time. It is a holistic system that encompasses physical, mental, and spiritual practices to promote health and well-being including a meditative means of discovering dysfunctional perception, a path to omniscience.

One of the main components of yoga is the practice of physical postures, which are designed to stretch, strengthen, and balance the body. Breathing exercises, are also an important part of yoga practice as they help to calm the mind and bring awareness to the breath. Beyond the physical practice, yoga also emphasizes the importance of mental and emotional health. Meditation and mindfulness techniques are used to cultivate awareness and promote relaxation, while the ethical principles of yoga, such as non-violence and truthfulness, provide a framework for living a fulfilling life.

Yoga has been shown to have numerous benefits for both physical and mental health. It can improve flexibility, strength, and balance, while reducing stress, anxiety, and depression. Additionally, it has been used as a complementary therapy for various health conditions. , such as chronic pain and cardiovascular disease.

Overall, yoga is a versatile and accessible practice that can benefit individuals of all ages and abilities. By incorporating physical, mental, and spiritual practices, yoga provides a holistic approach to health and well-being.

Guided Imagery

Visualization and guided imagery techniques offer another approach for stress reduction. Guided imagery, also known as katathym-imaginative psychotherapy, creates mental images of a calming and peaceful environment. The technic involves a trained practitioner or teacher assisting the participants in creating mental images that simulate or recreate sensory experiences. This can include visual images, sounds, tastes, smells, movements, and touch-related sensations such as texture, temperature, and pressure. The practitioner conducts the process in person with an individual or group.

Guided imagery techniques are effective in reducing stress. Firstly, they involve an element of distraction that redirects people’s attention away from stressors and towards an alternative focus. Secondly, they act as non-verbal instructions to the body and unconscious to behave as though the peaceful and relaxing environment were real. Finally, guided imagery can serve as a trigger to recall memories and sensations resulting from past relaxation practice.

Imagery techniques can be considered a type of guided meditation. Like other forms of meditation, the goal is to help individuals detach themselves from their thoughts and cultivate a relaxed state from which they can observe their thoughts and sensations without becoming embedded in them.

Mental imagery has been demonstrated to have a significant impact on various conditions and disorders, including depression, anxiety, phobias, bipolar disorder, post-traumatic stress disorder (PTSD), OCD and eating disorders.

Art Therapy in Treatment for Depression

The use of art therapy is one of the crucial technics of integrative treatment for depression that uses creative activities such as painting, drawing, sculpture, and other art forms to help individuals express their emotions. It has become increasingly popular in psychiatry as a complementary treatment to traditional talk therapy and medication.

One of the main advantages of art therapy is that it allows individuals to communicate non-verbally. By creating art, individuals can tap into their unconscious mind and express emotions that they may not be aware of or find difficult to put into words. Art therapy has been shown to be effective in treating a wide range of psychiatric disorders, including depression, anxiety, and trauma-related conditions. It can help individuals develop coping skills, improve self-esteem, and reduce stress and anxiety. It can also be used as a tool for self-exploration, helping individuals gain insight into their thoughts, feelings, and behaviours.

A fulfilling experience

In addition to its therapeutic benefits, art therapy can be an enjoyable and fulfilling experience for individuals. Creating art can be a form of self-expression and a way to relax and de-stress. It can also be a way for individuals to connect with others, as art therapy can be done in a group setting.

Art therapists are trained professionals who use art as a therapeutic tool. They work with individuals to help them explore their emotions, develop coping strategies, and improve their mental health. They also work with other mental health professionals, such as psychiatrists and psychologists, to provide a comprehensive treatment plan for individuals with mental health conditions.

History of art therapy

The Swiss psychiatrist and psychoanalyst Carl Gustav Jung, during his personal crisis, developed a temporary psychosis hallucinating images and hearing voices. He recognised those images as autonomous products of his psyche. Jung wrote down the phantasies and painted his hallucinations. Later he wrote transcribed the text and painted the images in a book called: “The Red Book”. The book is an example of a fascinating interaction between art and science. The use of painting and sculpturing was introduced by C.G. Jung in the book “The Psychology of the Transference”. Jung’s lifelong engagement with mixed media art-making positions him as a key figure in the development of art therapy, earning him the title of the “father of art therapy.”

During Jung’s second visit to America in 1913, he was introduced to the Greenwich crowd by the Jungian analyst Beatrice Hinkle. Greenwich crowd included notable artists and activists, including Margaret Naumburg and Florence Cane, who went on to establish the field of art therapy in the United States. Naumburg and Cane were deeply influenced by Jung’s theoretical ideas. In navigating a safe path for the birth of art therapy, Naumburg drew from many of Jung’s established ideas to develop her research and educational approach. Jung’s early clinical insights and theoretical ideas are gaining visibility and respect. Today, the historical details surrounding the development of art therapy in America are integrated back into the art therapy education.

Music Therapy in Treatment for Depression

The power of music on the mind is well-documented. Music therapy is a unique and effective integrative treatment method for depression. By using a person’s connection to music, it can bring about positive changes in their mood and overall well-being. Music therapy in the integrative treatment for depression can be utilized in a variety of ways. This could be singing, creating music with instruments, or simply listening to music. Moreover, music therapy can help individuals process a range of emotions, including happiness, excitement, sadness, calmness, and thoughtfulness. Music therapy has a number of benefits, including improving communication skills, self-awareness, concentration, and attention skills.

Live interaction between a person and their therapist is also an important aspect of music therapy. Improvisation can also be a significant part of music therapy, allowing individuals to create music on the spot. The way music affects the brain is complex, with various areas processing different aspects of music such as rhythm, emotions, and pitch.

Forms of music therapy

There are two forms of music therapy. Firstly, the receptive music therapy; secondly the active music therapy. Participants in the receptive music therapy are passive listeners to the music while the active music therapy engages the patients in the process of making music trough singing or playing music.

In both forms of music therapy, the therapist guides the patients. In the receptive therapy he chooses the music and animates the patients to discuss the songs. The active music therapy requires active participation in creating music through playing instruments, singing or even by composing the songs.

History of music therapy

Music has been an integral part of human life since the appearance of our species. Music therapy entered the field of psychiatry in the late 40ties of the 20th century. Since then, universities in the Western world offer training program in music therapy. E. Thayer Gaston is a key figure in promoting music therapy in the US.

Today the practitioners in music therapy are incorporated in the American Music Therapy Association founded in 1998.

Helping People with Depression

Depression is a life-threatening illness with destructive potential. It can turn a once lively partner or friend into someone who is lethargic, burdened by guilt, inner emptiness, and hopelessness.

One of the core symptoms of depression is the social withdrawal. The person affected may cut relationships and friendships due to the lost ability to interact socially.

One of the key points in helping people with depression is the protective network provided by family and friends. However, in their helplessness towards depression, family members often feel guilty or even angry towards the afflicted person. If the depressive phase persists, family members can feel overwhelmed and exhausted as they take on numerous tasks for the depressed person.

Be Informed about Depression

Gather information about depression and let the affected person understand the importance of treatment. You can also refer them to online depression forums, such as Depression and Bipolar Support Alliance (DBSA) or support groups. Talking to people who have dealt with depression provides easy access to the “first hand” information and shared experiences. Sometimes, it’s more convincing when someone who has experienced or recovered from depression reports that treatment was helpful.

You can also find information on family support groups through the regional associations and family self-help groups. Sometimes, just sharing your experiences with other family members can provide relief. Family members and friends of individuals with depression can find an online program with various exercises and videos. It demonstrates how to support the affected person and handle crises without overwhelming yourself.

Exercise Patience with Depressed People

Many people suffering from depression express complaints and despair, withdrawing from their surroundings. Be patient with them. Remind them that depression is a treatable illness and will pass. Do not try to convince them that their feelings of guilt are baseless. Avoid arguing about whether their negative perspective is “objectively” justified or not. Both approaches will not yield success.

It’s not easy to understand the subjective feeling of a person suffering of depression. Do not dismiss the affected person’s physical discomfort and health anxieties as exaggerated or “merely psychological.” because depressed individuals do not dramatize their experiences. It is depression that amplifies even mild pain or discomfort to unbearable levels.

Do not turn away from your depressed family member, even if they appear dismissive.

Avoid Well-Intentioned Advices to People with Depression

It is futile to advise a depressed person to “take a break” or go on a trip for a few days. Being in an unfamiliar environment can deepen patient’s depression even further.  Do not tell the affected person to “pull themselves together” because someone with depression cannot fulfil this demand. Such advice may even intensify feelings of guilt. The same applies to attempts to cheer them up. Instead, support your family member whenever they show initiative.

Understand Your Limits

If your family member is depressed for months, his illness will certainly affect you and the entire family. Therefore, it is crucial to recognize your own limits without feeling guilty. Patients suffering of clinical depression require professional treatment provided by psychiatrist or psychotherapist.

Being a helper, do not lose sight of your own mental help. Keep your interests and maintain your social connections. Be prepared that your family member will need your help for months, if not years.

Facilitating Professional Help for People with Depression

Depressed individuals often attribute their condition to themselves and do not consider seeking medical help. Due to the lack of motivation and hopelessness, people with depression believe that they cannot be helped. They also lack the energy to muster the strength for a doctor’s visit.

Always bear in mind that individuals with depression perceive reality through a “depressive lens,” which distorts their perspective. This may lead to decisions they may reconsider once they have recovered. Consider this, whenever possible, in all matters related to the person’s personal or professional future. In such situation, motivate the patient to seek medical advice as soon as possible.

Take the initiative and schedule an appointment by a psychiatrist or psychologist for your family member or friend suffering of depression. Even if he might initially reject offers of help, let him know you are there for him. Therefore, do not give up after the first attempt. Reiterate your concern and offer your assistance periodically.

Sometimes, it takes time to convince the person of depression to look for medical advice as the feel to be “beyond repair”.  You don’t necessarily have to disclose your suspicion of depression. Saying, “You don’t seem well. I’m concerned. Let’s get you checked by a doctor; I’ll accompany you if needed,” can make that first step easier.

Critical Concern: Suicidal Thoughts

Individuals with depression not only endure immense suffering but also lose all hope due to the illness. They doubt that help is possible and that their condition will ever improve. Perceiving their situation as hopeless, the suicide might appear to them as only a relief from the suffering. Suicidal thoughts and impulses are a very common symptom of depression. They turn depression into a life-threatening condition. If your family member or friend would experience suicidal thoughts, take action and seek medical help immediately.

Take Seriously Suicidal Thoughts

Suicidal threats and announcements

The misconception that a person who talks about suicide won’t act on it is false. Profound hopelessness and statements such as, “It all makes no sense anymore…,” “Eventually, it has to end…,” “Something has to happen now…” are indications of severe danger in individuals with depression.

Settling affairs and saying goodbye

Many people want to organize their affairs before suicide. They may give away valuable items, write their wills, or bid farewell to friends and family. Someone determined to commit suicide often appears calmer, more composed, and less desperate. Onlookers may mistakenly believe that the person is finally improving.

What Can I Do for Suicidal Person?

The most crucial aspect of acute suicidality is not to let alone the sufferer in the seemingly hopeless situation.

Initiate Conversation

If you suspect that a friend or family member is at risk of suicide, calmly and objectively address the issue with him. In most cases, talking about the distressing thoughts is a relief for the suicidal individual.

Care for the Person

The key is to buy time, as the desire to die is almost always a temporary state, and even in challenging life situations, the will to live usually returns. Show that you are there for them. Take responsibility for the individual during the acute situation. Accompany the person to the doctor or clinic. At night, this may be the psychiatric emergency department or the medical on-call service.

Seek Medical Emergency

Do not attempt to act as a therapist. Instead, support the individual in seeking professional help. You can seek assistance from a general practitioner or psychiatrist or visit a hospital if the patient is cooperative.

However, take immediate action when a person is immediately threatened by suicide but is unresponsive and unwilling to seek help.  Call for emergency medical assistance to ensure his safety. Provide the paramedics with a detailed account of the situation, and do not leave the affected person alone until the paramedics arrive.

Treatment for Depression. Overview

According to the World Health Organisation (WHO, 2020), depression is, along with anxiety, a highly frequent disorder with more than 300 million people affected globally. Unlike occasional mild mood changes that people experience from time to time, depression may develop into a debilitating, potentially fatal illness.

The origins of depression are in the centre of psychiatric and psychological research. Causes of depression are complex and not entirely identified. They involve multiple sources, including highly heterogeneous genetic and biological factors as well as psychosocial and environmental influences. Thus, no single cause can explain the onset of depression. There is a scientific consensus that depression originates from an interaction of biological, genetic, psychological, and social factors.

Treatment Options for Depression

The treatment of depression needs time and requires close cooperation with the psychiatrist and psychologist. The goal of the preliminary visit is to identify the problems and decide which treatment method would be the most suitable.

The therapy of depression consists of two main methods, such as psychotherapy and use of antidepressants, and can be supported by complementary treatment methods.

In case the symptoms are mild, treatment with psychotherapy would be the first choice. However, if the symptoms are more severe, the combination of medication and psychotherapy will be necessary.

Other treatment options are reserved for the severe or chronic course of the illness. This could be ECT (electroconvulsive therapy), TMS (Transcranial Magnetic Stimulation) or light therapy.

Today rarely used treatments methods are hormonal therapy with L-Thyroxine and using controlled sleep deprivation.

Psychotherapy for Depression

Psychotherapeutic methods used today for treatment of depression are:

1. Behavioral Therapy – Focuses on learning and unlearning behaviors, particularly helpful for depression where positive actions are encouraged, often using cognitive techniques and relaxation.
2. Cognitive Therapy – Targets negative thought patterns, teaching patients to reframe their thinking, enhancing self-control and realistic perceptions of their issues.
3. Interpersonal Therapy (IPT) – Addresses social conflicts and life transitions, focusing on areas like grief, role changes, and social skills to support patients’ relationships.
4. Psychodynamic Therapy – Explores unconscious conflicts from past experiences to resolve depression symptoms, especially useful in short-term formats for mild to moderate cases.
5. Person-Centered Therapy – Based on self-image and self-acceptance, encouraging patients to recognize and articulate their own feelings and needs.

Group therapies are also effective, particularly for grief and depression tied to chronic illness, offering peer support and shared experience.

Psychotherapy for Depression in Older Adults

The global increase in life expectancy is undeniable, with approximately 11% of the world’s population currently aged over 65. In some societies, this percentage has already surpassed 30%.

While longer life spans are a positive development, they come with implications for mental health. Depression takes central stage among individuals aged 65 and above. Age-specific psychosocial factors, such as loss of significant relationships and social isolation, likely contribute to this phenomenon.

Beginning with Sigmund Freud psychotherapy for older adults were considered as unsuccessful. Freud was arguing that old people are less adaptable not being able to change their mindsets. However, the recent studies proved efficacy of various psychotherapeutic technics, including psychodynamic methods, in treatment of depression in older adults.

A distinction is often made between full-blown depressive episodes and subsyndromal depression since many older individuals exhibit depressive symptoms that do not meet the severity criteria for a full episode.

Treatment for depression with Antidepressants

Antidepressants are commonly used to treat depression, helping make psychotherapy and social reintegration possible. They can enable outpatient treatment, aiming to help patients quickly return back to their social and professional life.

Antidepressants are a group of medications that elevat mood, increase the energy levels, and reduce physical symptoms of depression, like sleeplessness. They work by balancing the brain’s neurotransmitters, serotonin, noradrenaline, dopamin, and others, which concentration is lower in certain brain areas in people with depression. Types include SSRIs, SNRIs, NaSSA, MAO inhibitors, and tricyclic anf tetracyclic antidepressants.

These medications usually take a few weeks to work, and stopping them suddenly increases relapse risk. Antidepressants are not addictive, even with long-term use. For mild depression, herbal alternatives like St. John’s Wort may be used, but it has side effects and interacts strongly with other medications.

Major Depressive Disorder (MDD)

When people exhibit typical symptoms of Major Depressive Disorder, it is often dismissed as a temporary mood swing or passing sadness, which can be battelled with willpower. However, MDD is a genuine illness and not a sign of a “personality weakness.”

Major Depressive Disorder has episodic course and can continue for months, sometimes for years. It can be further categorized based on the symptom’s severity in mild, moderate, or severe episodes.

A form with frequent episodes is called Recurrent Depressive Disorder.

MDD with delusions or delusional thinking is described as Major Depressive Disorder with Psychotic Features.

Untreated MDD can have dire consequences, affecting people’s overall quality of life. The depressive symptoms can persist for an unforeseeable period because major depressive disorder is a serious and, in many cases, long-lasting condition. In the worst cases, it can lead to suicide. Recognizing signs and understanding the nuances of Major Depressive Disorder early and seeking appropriate help is essential for effective diagnosis and treatment.

Dysthymia

In contrast, Major Depressive Disorder is characterized by more severe symptoms and often occurs in phases (episodes). A depressive episode can be a one-time occurrence or recur at intervals. In dysthymia, the symptoms persist more or less constantly but with lower intensity.

Despite the lower symptoms’ intensity, dysthymia is associated with a high level of distress, primarily because the symptoms persist nearly continuously over an extended period with little variation in intensity. Women are diagnosed more often than men. The condition usually appears in adolescence or early adulthood, although people of all ages can be affected.

The causes of dysthymia are multifactorial. The best researched are the influence of genetic factors, dependence due to an overprotective upbringing and subsequent self-devaluation, and psychosocial influences such as social isolation.

Peripartum Depression

Mothers affected with peripartum depression experience symptoms such as extreme sadness, emotional numbness and anxiety. Their sleep is disturbed, and the energy level is reduced, limiting their abilities to carry for themselves and the child.

Peripartum depression carries risks not only for the mothers but also for their children. Researchers found that the children of mothers who suffered from depression during pregnancy or after delivery are at much higher risk of developing mental conditions. Also, the mature offspring of mothers with peripartum depression are at much higher risk of developing depressive disorders or anxiety in their later stages of life. 

Peripartum depression is a serious but treatable medical condition. The treatment requires the use of medication or psychotherapy, or ideally the combination of both.

Depression in Neurological Disorders

Depression frequently co-occurs with neurological disorders, substance use disorders, pain, personality changes, and cardiovascular diseases in older individuals.

Recognizing depression in patients with these neurological conditions is crucial for their overall well-being and treatment outcomes.

Healthcare professionals must take a multidisciplinary approach to manage these complex cases. The treatment often requires a multidisciplinary approach involving psychiatrists, neurologists, psychotherapists, and social workers. A combination of psychotherapy, pharmacotherapy, and medical interventions must be tailored to the specific needs of the patient.

Treatment Related to the Phase of Depression

Depression often occurs in phases, called depressive episodes. They can be solitary or recurrent. Prolonged episodes, exceeding two years, are classified as chronic. Approximately two out of ten patients experience chronic depression.

In some cases, recovery occurs within weeks or months, while half of patients experience recurring episodes, known as recurrent depression. The interval between episodes can be weeks to even years.

Suitable treatment options for particular phases of depression:

Acute therapy should begin as soon as an acute phase of the depression appears. It continues until the acute symptoms have significantly improved.

Maintenance therapy follows acute therapy and aims to stabilize the patient. When symptoms ease, treatment continues in maintenance therapy. It reduces relapse risk. Medication lasts about four to nine months; psychotherapy, eight to twelve months. Discontinuing the medication on one’s own as soon as one feels better often leads to relapses.

Relapse prevention: Untreated depression rarely resolves on its own. Prevention of recurrence begins once the patient’s mood has stabilized. Its goal is to prevent another acute episode in the long term.

The treatment of depression is not a “quick fix.” The process of healing takes time. The patients should be careful while judging the therapeutic progress without overestimating the temporary improvement. It’s not uncommon to experience setbacks even after a full recovery.

An important factors improving recovery and preventing depression is the involvement of family and friends in the treatment.

Treatment for Depression According to Symptoms’ Severity

Psychiatrist and patient decide together which therapy method can be used considering personal wishes and preferences, medical history, and the illness severity:

• Mild depression: Education, support, self-management, psychotherapy; cautious antidepressant use.
• Moderate depression: Psychotherapy or medication.
• Severe depression: Medication combined with psychotherapy.

Consequences of Untreated Depression

Depressed individuals who do not seek therapy quickly find themselves caught in a vicious cycle. The symptoms of depression strain family relationships and friendships, affecting also work performance. These illness-related social impairments are substantial and appear to persist in many patients even after the depressive episode have subsided. Consequently, individuals with depression tend to drink alcohol or take drugs as a coping mechanism.

Helping  Loved Ones or Friends with Depression

Helping a family member or friend through their battle with depression requires patience, empathy, and an understanding of the complex emotions they face. Transitioning from despair to hope and recovery is a journey that is manageable with unwavering support.

It’s crucial to remember that a person with depression may sometimes respond with rejection or withdrawal. This behaviour is a manifestation of the illness they are battling. Understanding this and respecting their ability to accept or decline external suggestions without taking offence can be immensely helpful.

Above all, family and friends should try to downplay the severity of the illness or offer well-meaning advice. These actions may inadvertently convey a lack of acceptance. Many people suffering from depression fear being labelled as “crazy” and fear rejection or mockery from their social circles. It’s extremely helpful to reassuring them that depression is an illness similar to physical disorders and that it can be cured.

Monitoring their treatment, such as ensuring they take their prescribed medications regularly or attend doctor’s appointments, is beneficial. However, it’s important not to make them feel like they’re losing control of their own lives.

Key Points about Depression

1. The first step prior to treatment is the correct diagnosis distinguishing MDD from other mental disorders.
2. Recognizing correctly depression is the “bottle neck” in the diagnostic and treatment process. Thus, only half of the depressive disorders are diagnosed properly.
3. From those accurately diagnosed only half are treated. This means that only every fourth person suffering from depression receives treatment.
4. Among the sufferers 10% -15% commit suicide.
5. Men are three times more likely to commit suicide than women.
6. A professional team consisting of a psychiatrist and psychologist can cure depression.

FAQ about Depression

Our German Clinic for Psychiatry and Psychology in Dubai is specialized in the treatment of distinct psychiatric disorders, among them therapy for Depression.

I am feeling really depressed. Can you tell me if I should see the psychologist or the psychiatrist?

If you are having trouble functioning in daily life, eg. working, parenting, grooming, etc., or you have lost your ability to sleep, seek psychiatric care.  For milder or more moderate feelings of depression psychotherapy from a psychologist will help you.  If you are uncertain, our psychologists are qualified to assess your level of depression and will make a referral for a psychiatric assessment if needed.

I feel fatigued, anxious, and demotivated and not enjoy things as I used to. Do you think the counselling can help me get rid of the symptoms?

You obviously suffer of depression. You can visit one of our psychologists. After an interview and short test, the severity of the symptoms can be assessed. If the symptoms are not severe and don’t last long, counseling would be the method of choice. In some cases, the medication can be indicated at the beginning to increase the energy, motivation, and mood. Combined with counseling, the medication can be gradually removed.

Is depression curable or just treatable with medication?

Depression is a curable condition. However, untreated, it can develop into chronic, lifelong suffering. Therefore, it is critical for individuals with depression to engage in therapy as soon as possible. The state-of-the-art treatment for depression combines medication and psychotherapy. Medication can suppress the symptoms within a few weeks creating a sound foundation for the psychotherapy. However, medication alone will lose eventually its efficacy. On the other hand, psychotherapy used without medication wouldn’t be able to “unwind” severe depressive symptoms.

Are drugs the best treatment for depression?

Medications helps to quickly restore person’s functioning but it’s not healing depression per se. The purpose of treatment with antidepressants is to alleviate symptoms of severe depression, such as feeling down and not being capable to deal with social and professional obligations. They help to restore the sleep, lift the mood, and suppress the anxiety. In most of the cases depression is the effect of psychological malfunction due to accumulation of conflicts the individual is not aware of or feels incapable to solve. However, using only medication will not solve such problems by default. The individual needs time and guidance to find a suitable solution. Once such solution is found and implemented in individual’s life, the medication would be obsolete.

Are depression and anxiety related?

Yes, depression and anxiety are often related. While they are distinct mental health disorders, they frequently coexist and share common symptoms, such as excessive worry, irritability, and difficulty concentrating. Additionally, experiencing one disorder can increase the risk of developing the other, and they often respond to similar treatment approaches.

What is the treatment for depression?

The treatment for depression typically includes a combination of therapy, medication, and lifestyle changes. Therapy, such as cognitive-behavioral therapy (CBT), helps individuals identify and change negative thought patterns and behaviors. Medications, such as antidepressants, can help rebalance brain chemicals. Lifestyle changes, like exercise, adequate sleep, and stress management, also play a crucial role in managing depression.

Are depression rates increasing?

Yes, depression rates have been increasing globally over recent years. Factors such as societal pressures, economic stressors, and lifestyle changes contribute to this rise. Additionally, increased awareness and recognition of mental health issues may also play a role in the reported increase in depression rates.

Can depression be genetic?

Yes, depression can have a genetic component. Research suggests that individuals with a family history of depression are at a higher risk of developing the disorder themselves. Genetic factors can influence a person’s susceptibility to depression, but environmental and psychological factors also play significant roles in its development.

Will depression go away on its own?

The duration of depression varies widely among individuals, making it challenging to determine an average timeframe. However, it’s unlikely for depression to resolve without treatment. Addressing chronic depression typically involves a multifaceted approach, including medication, therapy, self-care practices, and adopting healthy lifestyle habits such as maintaining a balanced diet and regular exercise.

Self-Assessment for Depression (Beck Inventory)

Beck Depression Inventory is psychometric evaluation of the depressive symptoms in adults with social anxiety disorder. (BDI) is used to assess levels of depressive symptoms in socially anxious adults.

BDI is a self-assessment for depression helping to identify the severity of an individual’s depressive symptoms. Beck Depression Inventory was developed in 1961 by psychologist Aaron Beck. Since then, BDI has been widely used in clinical and research settings to diagnose and measure the severity of depression. The questionnaire contains 21 questions that assess various symptoms of depression, including mood, cognitive symptoms, and physical symptoms. Total scores range from 0 to 63, with higher scores indicating more severe depression.

This Beck’s Depression Assessment helps to identify a clinical depression. However, the test doesn’t replace a thorough psychiatric and psychological evaluation, necessary to secure the diagnosis.

Beck’s Self-Assessment for depression

This depression inventory can be self-scored. The scoring scale is at the end of the questionnaire.

1. Question

I do not feel sad 1 I feel sad; 2 I am sad all the time and I can’t snap out of it; 3 I am so sad and unhappy that I can’t stand it

2. Question

0 I am not particularly discouraged about the future 1 I feel discouraged about the future; 2 I feel I have nothing to look forward to; 3 I feel the future is hopeless and that things cannot improve

3. Question

0 I do not feel like a failure 1 I feel I have failed more than the average person. 2 As I look back on my life, all I can see is a lot of failures 3 I feel I am a complete failure as a person

4. Question

I get as much satisfaction out of things as I used to. I don’t enjoy things the way I used to. 2: I don’t get real satisfaction out of anything anymore. I am dissatisfied or bored with everything

5. Question

I don’t feel particularly guilty 1 I feel guilty a good part of the time; 2 I feel quite guilty most of the time; 3 I feel guilty all of the time

6. Question

0 I don’t feel I am being punished 1: I feel I may be punished; 2: I expect to be punished; 3: I feel I am being punished

7. Question

0 I don’t feel disappointed in myself 1 I am disappointed in myself 2 I am disgusted with myself 3 I hate myself

8. Question

0 I don’t feel I am any worse than anybody else 1 I am critical of myself for my weaknesses or mistakes; 2 I blame myself all the time for my faults; 3 I blame myself for everything bad that happens

9. Question

I don’t have any thoughts of killing myself. 1 I have thoughts of killing myself, but I would not carry them out. 2 I would like to kill myself. 3 I would kill myself if I had the chance

10. Question

I don’t cry any more than usual. I cry more now than I used to. 2: I cry all the time now. 3: I used to be able to cry, but now I can’t cry even though I want to

11. Question

0 I am no more irritated by things than I ever was 1 I am slightly more irritated now than usual 2 I am quite annoyed or irritated a good deal of the time 3 I feel irritated all the time

12. Question

I have not lost interest in other people I am less interested in other people than I used to be. 2: I have lost most of my interest in other people I have lost all of my interest in other people

13. Question

0 I make decisions about as well as I ever could 1 I put off making decisions more than I used to 2 I have greater difficulty in making decisions more than I used to 3 I can’t make decisions at all anymore

14. Question

0 I don’t feel that I look any worse than I used to. I am worried that I am looking old or unattractive 2: I feel there are permanent changes in my appearance that make me look unattractive I believe that I look ugly

15. Question

0 I can work about as well as before 1: It takes an extra effort to get started at doing something. 2. I have to push myself very hard to do anything. I can’t do any work at all

16. Question

0 I can sleep as well as usual 1 I don’t sleep as well as I used to 2 I wake up 1-2 hours earlier than usual and find it hard to get back to sleep 3 I wake up several hours earlier than I used to and cannot get back to sleep

17. Question

0 I don’t get more tired than usual 1 I get tired more easily than I used to 2 I get tired from doing almost anything 3 I am too tired to do anything

18. Question

0 My appetite is no worse than usual 1. My appetite is not as good as it used to be. 2 My appetite is much worse now. I have no appetite at all anymore

19. Question

0 I haven’t lost much weight, if any, lately. I have lost more than five pounds I have lost more than ten pounds I have lost more than fifteen pounds

20. Question

I am no more worried about my health than usual 1: I am worried about physical problems like aches, pains, upset stomach, or constipation. 2: I am very worried about physical problems, and it’s hard to think of much else I am so worried about my physical problems that I cannot think of anything else

21. Question

I have not noticed any recent change in my interest in sex. I am less interested in sex than I used to be. 2 I have almost no interest in sex. I have lost interest in sex completely.

Interpreting the Beck Depression Inventory

Now that you have completed the Self-Assessment questionnaire, add up the score for each of the twenty-one questions by counting the number to the right of each question you marked. The highest possible total for the whole test would be sixty-three. This would mean you circled number three on all twenty-one questions. Since the lowest possible score for each question is zero, the lowest possible score for the test would be zero. This would mean you circle zero on each question.

You can evaluate your depression according to the table below:

Total Score__________ Levels of Depression

1-10________________ These ups and downs are considered normal

11-16_______________ Mild mood disturbance

17-20_______________ Borderline clinical depression

21-30_______________ Moderate depression

31-40_______________Severe depression

over 40_____________Extreme depression

Diagnosis and Treatment for Depression at CHMC in Dubai: +971 4 4574240

Famous people diagnosed with depression:

• Abraham Lincoln
• Georgia O’Keeffe
• Theodore Roosevelt
• Robert Schumann
• Emily Dickinson
• Ludwig van Beethoven
• Edgar Allan Poe
• Marie Curie
• Mark Twain
• Vincent van Gogh
• Virginia Woolf