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تاريخ التسجيل : 15/09/2008
 | موضوع: Depression: Pathophysiology, clinical manifestations, and diagnosis part1  الأربعاء أكتوبر 01, 2008 4:43 pm | |
| Depression: Pathophysiology, clinical manifestations, and diagnosis Apr 12, 2001 Randall H Paulsen, MD
"Normal depression" occurs in the course of any active, eventful life. Developmental psychologists consider it a key emotional stage in early development and a predictor of emotional maturity in adult life. The capacity for depression begins with such early experiences as being able to feel sorry for what one has done and to feel sadness, which connects the young child to the mother when she is away. This capacity for a depressive link to mothers is the basis of object constancy and is a marked improvement over the need to monitor, be vigilant, and see the mother in person.
Another important form of normal depression has to do with expectations, ambitions, and goals. We often experience a depressive mood when we see too great a difference between our expectations and our actual performance. Both depression and anxiety are primary signals that help guide the individual through the complexities of adult life. As an example, when we are overly disappointed and depressed about our performance, it is important to look at the reasonableness of our expectations as well as how to improve.
The interpersonal discussion of depressive feeling is a fulcrum for most forms of psychotherapy, counseling, and helping relationships. Depression is a building block for all human relationships. It is one of the major feeling states that indicates the need for help and connection. The patient asks for help in providing context, meaning, and understanding. This can successfully occur within a 10-minute primary care visit as well as any helping context.
The most important single marker of pathologic depression is that it interferes with the person's ordinary expectable function. This expectable function can apply to self care, the maintenance of important relationships, the performance of work-related tasks, and economic self-support. It is difficult to make a case for a major depression, regardless of symptom severity, without observable interference with function.
The time course and severity of symptoms is a second clue to the presence of pathologic depression. Many patients have depressive and anxious symptoms and score positively on screening tests for depression. However, these symptoms often have not evolved into actual syndromes requiring treatment. Treating patients with positive screening tests who do not have pathologic depression is neither cost-effective nor beneficial.
A large proportion of patients regard their primary care physician as their only provider of mental health therapy. Up to 50 percent of primary care visits in an average clinical day have been estimated to involve some component of emotional distress that raises the possibility of a psychiatric condition [1]. Depression itself is one of the top five diagnostic entities that occur in primary care settings. Thus, it is necessary for the primary care clinician to have a simple approach to the detection of depression and to be able to initiate treatment. Clinicians also need knowledge and a network that enable them to refer to therapists and psychiatrists for assistance both in adjusting medication and in providing counseling to help the patient's psychosocial recovery from the depressive episode.
The psychosocial aspects of depression and the pathophysiology, risk factors, clinical manifestations, and diagnosis of major depressive disorder are reviewed here. The treatment of depression is discussed separately. (See "Treatment of depression-I").
PSYCHOSOCIAL ASPECTS OF INDIVIDUAL PATIENTS – The duality of emotional life is an important concept to bear in mind when encountering patients with depression. Anxiety and depression in their normal range provide guidance and emotional moorings for each of us. Anxiety provides the warning signals of danger; depression provides the bearing signals during the journey, the emotional measure of distance from attachments and ideals. Anxiety has its positive pole, security. Depression has its positive poles, success in work and intimacy in relationships.
A patient may tell his or her primary care doctor about feelings of anxiety and depression during a visit. The doctor has to listen carefully to determine whether the emotions have begun to interfere with function, ie, are pathologic.
Another important duality that affects depression is that between body and mind. The patient will not always tell the physician in words. Sometimes the patient will communicate with his her body, posture, energy and movement. Depression is an important affect (emotion) in that it almost always contains both physical (somatic) and psychological aspects.
Depressed patients may present with weight loss or gain, sleep disturbances, loss of energy, or slowness of movement. They may also present with feelings of rotting inside and unattractiveness. Patients often have incomplete knowledge of their bodies as well as their minds.
Knowledge is extended in the dialogue, both verbal and physical, with the primary care physician. Patients discover meanings as they talk; doctors put together findings and hypothesize out loud for patients' considerations. Psychiatry and primary care are companion disciplines, each starting with the mind and body, respectively, and moving to include its counterpart.
There is an important distinction between temperament and character.
• Temperament is the biologic emotional endowment that follows individuals through life: the active, assertive baby who becomes the athletic thrill seeker; the fussy, picky eater who becomes a somatic worrier. Terms like placid, "hyper," a "good sleeper," or a "poor sleeper" often refer to underlying temperamental qualities. Temperament is a physical concept, while character is a more psychologic one.
• Character is the sum of experience, identifications, and interactions that make up the enduring signature of a person. Character is the basic style with which a person relates to others and to himself or herself.
Antidepressants are primarily given to address physical issues of temperament. They have also given primary care physicians a new tool to address these physical symptoms when they interfere with the patient's function.
The long-standing nature of the primary care relationship allows consideration of temperament and character to enter the evaluation of depression. The acute appearance of depressive symptoms needs to be seen against the backdrop of each patient's personality and, equally important, his or her manner of interaction with the physician.
To use an extreme example, a substance-abusing patient may have a primary relationship to the substance and a secondary relationship to the physician; this can leave the perceptive physician with a feeling of depersonalization. The doctor-patient context comes to resemble an abusive relationship in which lost prescriptions, unheeded advice, and even forgeries provide evidence that the doctor's office has become another arena to pursue the substance. Acute depression in this context could be either manipulation, withdrawal, or possibly an emotional signal of loss (perhaps the patient is threatened with wife and family leaving), which may begin concerted efforts at change. A long-standing relationship would allow the doctor to ask the necessary questions to differentiate among those three possibilities.
EPIDEMIOLOGY AND RISK FACTORS – The point prevalence for major depressive disorder in Western industrialized nations is 2.3 to 3.2 percent for men and 4.5 to 9.3 percent for women. The lifetime risk for major depressive disorder is 7 to 12 percent for men and 20 to 25 percent for women. Major depression occurs in 2 to 4 percent of individuals in the community, 5 to 10 percent of primary care patients, and 10 to 14 percent of medical inpatients [2]. Depression in the elderly is associated with significant health care costs [3] and functional decline [4].
The primary risk factors for major depressive disorder include:
• Female gender
• History of depressive illness in first degree relatives
• Prior episodes of major depression
The explanation for the female preponderance is not entirely clear. Contributing factors may include the high incidence of postpartum depression, social factors (eg, history of childhood sexual abuse, low self-esteem), and gender differences in the metabolism of noradrenergic and serotonergic neurotransmitters [5,6]. Both animal and human studies suggest that early stressors (eg, childhood sexual abuse) cause long-term dysregulation of the hypothalamic-pituitary-adrenal (HPA) axis similar to that seen in depressed patients [7]. The HPA axis in women may be more susceptible to stress-induced dysregulation than in men, contributing to an increased vulnerability to depression in adult women.
Other risk factors are a more remote family history of depressive disorder, lack of social supports, significant stressful life events, and current alcohol and substance abuse.
continue with part 2
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