DepressionDepression is one of the most common mental disorders and manifests itself u.a. depressed mood, impulsive disorders and reduced feelings.
Depression is a mental disorder characterized by a state of depressed mood, lack of interest, and reduced drive. They are often accompanied by physical complaints.
Those affected by depression are usually restricted in their way of life, often finding it difficult or impossible to perform their everyday tasks. Patients have a high level of distress and suffer from brooding, concentration problems and self-doubt.
Epidemiology
Depression is more common in women than in men. Women are almost twice as likely to suffer from depression as men. Women also have an earlier onset of illness, longer episode duration, and a higher risk of relapse for further depressive episodes compared to men. The disease often manifests itself for the first time after the age of 30. The most common form of depression is depression of the first year of life, but it can occur at any age. There is also a tendency for the rate of illness to increase, especially in younger age groups. Prevalence rates between 15-20% until the age of 18 are estimated. The first signs of cognitive dysfunction have been described. In older age, depression is the most common mental disorder. Prevalence estimates for patients in nursing homes are up to 50%. This is accompanied by functional impairment, reduced quality of life, cognitive impairment, and increased suicidality. Lifetime prevalence, i.e., the risk of developing depression over the course of a lifetime, is 16-20%. The annual incidence is 1-2 disorders per 100 persons.
Causes
The etiology of the disease is multifactorial. It is amed that genetic, neurobiological, social-psychiatric and environmental factors, among others, have an influence on the development of the disease. Psychological factors such as traumatic experiences are also taken into account. Personality factors play a role in the development of depression. Marital status also influences the risk of developing the disease. Thus, the presence of a trusting personal relationship as a protective factor counteracts the emergence of depression. Likewise, a higher level of education correlates. Secure occupational employment with lower rates of depression.
Risk factors
Risk factors for the development of a depressive disorder are, for example:
– previous depressive episodes in the family history – suicide attempts in one's own past or family history – comorbid somatic diseases – comorbid substance abuse resp. substance dependence – the presence of currently stressful life events – lack of social support.
Pathogenesis
None of the following explanatory approaches has yet been able to provide a convincing monocausal explanation for the etiopathogenesis of depression. Another thing to keep in mind about possible pathogenesis models is that the term depression encompasses a broad spectrum of mental disorders.
It is strongly amed that this is a multifactorial event. On the one hand, several studies show an increased likelihood of the occurrence of affective disorders in genetically vulnerable individuals when they are confronted with trigger factors such as breakups, professional disappointments (vulnerability-stress model).
Epidemiological studies also suggest a familial clustering of depressive disorders. For example, first-degree relatives have about a 50% higher risk of developing a depressive disorder compared to the general population. Affective disorders seem to be (co-)caused by alterations on different genes.
Another influence seems to be stress management, as animal research has shown.
A psychodynamic model of the relationship histories of depressed individuals describes an increase in their sensitivity to separation.
A reinforcement-theoretic interpersonal explanatory model ames that potentially reinforcing events quantitatively and qualitatively z.B. Decrease due to separation, social isolation, or poverty. The absence of positive reinforcements (rewards) that contributed to the well-being of the affected person lead to depressive moods.
Another approach to explain the pathogenesis are cognitive psychological hypotheses, which ame cognitive disorders as a trigger. They suggest that depressive disorders occur when a person processes situational triggers with negative, distorted cognitions that are out of touch with reality. Reduced drive with increased fatigability. Activity limitation.
70-80% of patients also report feelings of anxiety as an expression of strong insecurity and fear of the future. In addition, patients are quickly irritable and overwhelmed z.B. in social contacts. Additional symptoms include u.a. decreased concentration/attention, guilt/feelings of worthlessness, pessimistic future prospects, suicidal thoughts, sleep disturbances and decreased appetite.
Depression leads to severe impairment of physical and mental well-being. Patients also show severe impairment in social relationships and ability to work.
Comorbidities
Depressive disorders have a high comorbidity with other mental disorders. The comorbidities have a negative impact on the course of the disease, and sufferers have a higher risk of chronicity, a less favorable prognosis and an increased risk of suicide. The most common symptoms are anxiety. Panic disorders associated with depression. Other common and unfavorable combinations that depressed patients exhibit are with substance dependencies (alcohol, medications, and drugs) and with eating disorders, personality disorders, and obsessive-compulsive disorders.
Further, depression is associated with increased risk of somatic pathologies such as atherosclerotic cardiovascular disease, cancer, migraine, bronchial asthma, allergies, diabetes mellitus, and infectious diseases, for example.
Diagnostics
Patients often do not describe depressive symptoms directly, but complain about somatic complaints.
These symptoms, which may indicate the presence of depression, are, for example: physical fatigue, sleep disturbances, appetite disturbances, stomach prere, diffuse headache, feeling of prere in the throat and chest, globus sensation, dizziness, visual disturbances, muscle tension, loss of libido or memory disturbances. The presence of other symptoms of a depressive disorder should therefore be actively explored.
One diagnostic option for depressive disorders is the "two-question test". If this is positive, all relevant main and secondary symptoms must be queried. In addition, in the case of clinical suspicion, the presence of somatic symptoms should also be taken into account. Psychotic additional symptoms are interrogated.
Furthermore, there are screening questionnaires to facilitate the recognition of a depressive disorder. Examples are the WHO-5 questionnaire on well-being, the General Depression Scale and the Patient Health Questionnaire (PHQ-D). If psychological comorbidity is also suspected, further symptoms must be actively explored in accordance with the guideline if screening questions confirm the suspicion. Furthermore, a somatic, especially brain-organic cause and abuse of psychotropic substances should be excluded.
Classification systems
In the international classification system ICD-10, depressive disorders are included in the category "affective disorders. Major depression" and "mania" form the two poles of the mood spectrum. To diagnose a depressive disorder according to ICD-10, at least two main symptoms must last at least two weeks.
ICD-10 classification
The ICD-10 distinguishes between mild (two additional symptoms in addition to the main symptoms), moderate (three to four additional symptoms in addition to the main symptoms) and severe (at least four additional symptoms in addition to the main symptoms) in depressive episodes. The degree of severity is determined by the number of main and additional symptoms met.
In addition, a distinction is made between monophasic, relapsing/chronic course and depressive disorder in the context of a bipolar course. In the context of depressive disorder, somatic or psychotic symptoms (delusions, hallucinations, depressive stupor) may also occur.
Main symptoms
Depressed, depressive mood Loss of interest, joylessness Lack of drive, increased fatigability Additional symptoms
Decreased concentration and attention Decreased self-esteem and self-confidence Feelings of guilt and worthlessness Negative and pessimistic future prospects Suicidal thoughts/actions Sleep disturbances Decreased appetite
DSM-5 classification
In the DSM-5 classification, in order to make a diagnosis of Major Depressive Disorder, the presence of five main symptoms is required. The classification also offers the possibility of dividing the remission into partial or full remission.
If depressive symptoms exist for more than two years, this is called persistent depressive disorder.
Therapy
At the beginning of therapy, an educational talk should be held with the patient, during which the patient should be given realistic hope and be relieved. The general therapy goals are to reduce the symptoms. At best achieve a complete remission of the same. As a result, mortality (v.a. by suicide) be lowered and professional and psychosocial functioning be restored. In addition, the aim is to regain mental balance and reduce the likelihood of a relapse. According to the guideline, there are four treatment strategies:
– active waiting ("watchful waiting" / low-threshold psychosocial intervention) – drug treatment – psychotherapeutic treatment – combination therapy.
In addition, various other therapeutic methods are used in the treatment of depression, such as light therapy, sports and exercise therapy, sleep deprivation therapy or electroconvulsive therapy.
Depression therapy can be divided into three phases: acute therapy, maintenance therapy, and long-term or. Relapse prevention. Response to a form of therapy is amed when there has been at least a 50% reduction in depressive symptoms, as assessed by self- or other-assessment procedures.
Drug therapy
The most important group of substances available for the treatment of depressive disorders are antidepressants. This group includes:
– Tri- (and tetracyclic) antidepressants resp. Melatonin receptor agonists (MT1/MT). Serotonin 5 HT2C receptor antagonists (agomelatine).
In addition, unclassified antidepressants (trazodone), lithium salts, and phytopharmaceuticals (St. John's wort) are available for therapy.
Considerable differences between the substance classes lie in toxicity and side effects. This is particularly important because more than half of patients treated with antidepressants complain of adverse side effects.
As a reserve antidepressant, for example, the agent tranylcypromine may be considered as an irreversible inhibitor of MAO-A and MAO-B. It is used especially for treatment-resistant depression, or when other antidepressants are not tolerated or are contraindicated. It should be noted that patients must maintain a low-tyramine diet during therapy with tranylcypromine.
Prognosis
Depression typically shows an episodic course. The phases of the disease are temporary (untreated ca. 6-8 months) and often subside even without therapeutic measures. Effective therapies shorten the mean duration of episodes to approx. 16 weeks.
The course of depressive disorders shows great interindividual variability. There are patients who experience remission of depressive episodes and are subsequently completely symptom-free, whereas other patients have residual symptomatology with incomplete remission. Furthermore, there are recurrent depressions. 70-80% of depressive moods have a recurrent course. The risk of recurrence decreases the longer the patient is free of recurrence. In addition, depression can last for years. People suffering from depression have an increased risk of suicide. For more detailed information, please refer to the literature.
Prophylaxis
Preventing depression is only possible to a limited extent. However, one factor that lowers the risk of depression is, for example, the presence of stable social ties. Pharmacotherapy plays a role in reducing the risk of recurrence of depression. On the other hand, psychoeducation plays a major role. A trusting therapeutic relationship is also important to improve patient compliance. Psychotherapy can also be considered.