Depression: When everything seems boring, there’s a problem

People experience sadness at times in their lives, usually in response to a saddening event. Sometimes people feel unhappy for no obvious reason, or react to a minor occurrence that acts as a trigger, with a “bad mood” lasting for days. This is “depression”. Unlike sadness, this is not a normal emotion. Depression is pathological, sadness is not.

In addition to the pervasive gloom, the patient feels no interest in things that he enjoyed earlier; everything seems “boring”. He either has no appetite or eats excessively. His sleep is disturbed, sleeping either too much or too little. He feels tired and listless all day. So he sits around, achieving very little by the end of the day. Even if he overcomes the lethargy and gets down to work he is slow because his attention is not sustained long enough to plan his work efficiently. By the time he is done he is left feeling guilty, worthless and more tired than he should be.

Feeling hopeless about things ever getting better, he may break down in tears, or even think of ending his life.

Depression may come in episodes lasting several months at a time; the patient feels perfectly fine and is cheerful and active between episodes. A depressed mood with its associated symptoms lasting over two weeks constitutes a Depressive Episode. There are subtypes of depression like Seasonal Affective Disorder’, Post-partum Depression, Dysthymia, etc. People may also show signs of depression as part of other conditions like schizophrenia, dementia or some types of personality disorder.

Episodes of depression may be part of a clinical picture called Bipolar Disorder or Manic-Depressive Disorder. Here the patient experiences episodes of mania or “high” moods at times and “low” moods at other times. This is a separate clinical entity. Its immediate treatment depends on the presenting symptoms while long-term management is primarily with mood-stabilisers.

What causes depression?
There are several hypotheses, both biological and psychological, none of which can explain all cases of depression. Currently, it is believed that biological, psychological and social factors all have a role to play in causing depression.

Why should depression be treated?
If depression is episodic it should eventually clear up even without treatment, shouldn’t it? So why can’t you simply wait it out? Why treat it?

The reason is that it is a disabling condition, affecting every aspect of the patient’s life — his confidence and sense of well-being, his relationships, his work, things like sleep and appetite that people usually take for granted, and his general health due to neglect. Untreated, it takes 8-9 months to resolve. Besides, a significant percentage of patients attempt/commit suicide within this time because of the guilt, helplessness and lack of hope that make their misery intolerable.

Treatment
After taking a detailed history the doctor rules out physical conditions like hypothyroidism, and may ask for lab tests to check for chronic infections or electrolyte imbalances, if they seem necessary. If the depression is a symptom of another psychiatric condition it will come to light during this interview.

The decision to start a course of antidepressant medication is made only after a Mental State Examination to determine whether the symptoms are severe enough to warrant pharmacological treatment. Mild situational depression can often be handled by counselling or a few sessions of psychotherapy.

Patients prescribed medicines also benefit from psychotherapy along with regular medication.

Medicines, once started, have to be continued for several months with reviews at intervals by the treating psychiatrist. The basis for use of medicines to treat “feelings” like depression is that no matter what the cause, the symptoms are ultimately mediated by chemicals in the brain that make thoughts and feelings possible.

Apart from the existing body of research that proves these agents to be truly effective, every clinician has seen patients’ symptoms reduce dramatically with the use of medications — and patients have testified to the same. Therefore, judicious use of medicines along with appropriate psychotherapy can give patients the support needed to deal with the debilitating effects of a depressive episode.

— Dr Shyamala Vatsa is a consultant psychiatrist