Depression and depressive disorder

                     Depression and depressive disorder

    As many as two third people with depression do not realize that they have a treatable illness and therefore do not seek professional help. In addition, persistent ignorance and misperceptions of the disease by the public, including health providers, as a personal weakness or failing that can be willed or wished away, leads to painful stigmatization and avoidance of the diagnosis by many of those affected. 

     In the primary care setting where many of these patients first seek treatment, the presenting complaints often can be somatic, such as fatigue, headache, abdominal distress, or sleep problems. Classifies the depressive disorders, major depressive disorder (including major depressive episode), persistent depressive disorder  (dysthymia), premenstrual dysphoric disorder, and depression disorder due to another medical condition. In addition,  depression may be further categorized by specifiers that include peripartum onset, seasonal pattern, melancholic features, mood-congruent or mood-incongruent psychotic features, anxious distress, and catatonia. The common feature of depressive disorders is the presence of sad, empty, or irritable mood, accompanied by somatic and cognitive changes that significantly affect the individual's capacity to function. what differs among them are issues of duration, timing, or presumed etiology. 

    Pathophysiology: 

 The underlying Pathophysiology of the major depressive disorder has not been clearly defined. Current evidence points to a complex interaction between neurotransmitter availability and receptor regulation and sensitivity underlying the effective symptoms clinical and preclinical trails suggest a disturbance in central nervous system serotonin activity as an important factor. Other neurotransmitters implicated include norepinephrine, dopamine, glutamate, and brain-derived neurotrophic factor. However, drugs that produce only an acute rise in neurotransmitter availability, such as cocaine or amphetamines do not have the efficacy over time that antidepressants do. 

Etiology: 

    The specific cause of major depressive disorders is not known. As with most psychiatric disorders, major depressive disorder appears to be a multifactorial and heterogeneous group of disorders involving both genetic and environmental factors. Evidence from family and twin studies indicates that with depression that develops in early childhood, the transmission from parents to children appears to be related more to psychosocial influences than to genetics. Adolescent-onset and adult-onset depression, likewise reflect an interaction between genes and environmental stressors. 

Sign and Symptoms: 

  Most patients with major depressive disorder present with a normal appearance. In patients with more severe symptoms, a decline in grooming and hygiene may be observed, as well as a change in weight. Patients may also show the following:
- Psychomotor agitation or retardation. 
- Flattening or loss of reactivity in the patient's affect(emotional expression)
- Psychomotor agitation or restlessness.
- Depressed mood: for children and adolescents, this can also be an irritable mood.
- Diminished interest or loss of pleasure in almost all activities (anhedonia).
- Significant weight change or appetite disturbance: for children, this can be a failure to achieve expected weight gain. 
- Sleep disturbance (insomnia or hypersomnia). 
- Fatigue or loss of energy.
- Feelings of worthlessness.
- Diminished ability to think or concentrate; indecisiveness. 
- Recurrent thoughts of death recurrent suicidal ideation without a specific plan, or a suicide attempt or specific plan for committing suicide. 

Clinical Presentation:

   Patients with the major depressive disorder may not initially present with a complaint of low mood, anhedonia, or other typical symptoms. In the primary care setting, where many of these patients first seek treatment, the presenting complaints often can be somatic(e.g. fatigue, headache, abdominal distress, or change in weight). Patients may complain more of irritability or difficulty concentrating than od sadness or low mood. 

  Children with the major depressive disorder may also present with initially misleading symptoms such as irritability, the decline in school performance, or social withdrawal. Elderly persons may present with confusion or a general decline in functioning; they also experience more somatic complaints, cognitive symptoms, and fewer complaints of sad or dysphoric mood. 

Familial, Social And Environmental Factors: 

  Depression can be familial. Thus, thorough family history is quite important. Familial, social, and environmental factors appear to play a significant role in the course of depressive illness in children and youths, even in preschool children. Rene Spitz described anaclitic depression (marasmus) in the infant being raised in an orphanage and in hospitalized children whose parents were not allowed to visit. 

Dysphoric Mood:

   A dysphoric mood state may be expressed by patients as sadness, heaviness, numbness, or sometimes irritability and mood swings. They often report a loss of interest or pleasure in their usual activities, difficulty in concentration, or loss of energy and motivation. Their thinking is often negative, frequently with feelings of worthlessness, hopelessness, or helplessness. 

Psychosis:

  Patients with major depressive disorder commonly show ruminative thinking. Nevertheless, it is important to evaluate each patient for evidence of psychotic symptoms, because of this affected initial management. 

    Psychosis, when it occurs in the context of unipolar depression, is usually congruent in its content with the patient's mood state; for example, the patient may experience delusions of worthlessness or some progressive physical decline. 

Progression: 

   The major depressive disorder has significant potential morbidity and mortality, contributing as it does to suicide incidence and adverse outcomes of medical illness, disruption in interpersonal relationships, substance abuse and lost work time with appropriate treatment 70-80% individuals with major depressive disorder can achieve a significant reduction in symptoms, although as many as 50% patients may not respond to the initial treatment trial. 

    Education plays an important role in the successful treatment of major depressive disorder. Over the long term, patients may also become aware of signs of relapse and may seek treatment early. Patients should be aware of the rationale behind the choice of treatment, potential adverse effects, and expected results. The involvement of the patient in the treatment plan can enhance medication compliance and referral to counseling.  Family members also need to be educated about the nature of depression and may benefit from supportive interactions. Engaging the family can be a critical component of a treatment plan, especially for pediatric and late-onset depression. Family members are helpful information, can ensure medication compliance, and can encourage patients to change behavior that perpetuates depression. 

   Common mental disorders are increasing worldwide. Between 1990 and 2013, the number of people suffering from depression and anxiety increased by nearly 50%. Close to 10% of the world's population is affected by one or both of these conditions. Depression alone accounts for 10% of years lived with disability globally. 

   Depression increases the risk of other noncommunicable diseases, such as diabetes and cardiovascular disease.