Depressive disorder [depression]

Depression is a term used to describe the presence of a sad, empty, or irritable mood. It is accompanied by physical, physiological, and cognitive changes that significantly affect the individual’s ability to function.

The depressive episode is not the same as a diagnosis of major depressive disorder (or major depression). This is because many people can have more or less severe mood swings, up to and including full-blown bipolar disorder. Depression may therefore be only one symptom, although it is usually the most unwelcome for the person seeking help at these stages.

Depressive disorder is common in the general population and therefore well known. In fact, it is estimated that 10% to 15% of the population suffers from it, with a higher incidence among women. Major depression is associated with a high mortality rate. Up to 15% of people with major depression die by suicide.

However, most depressed people do not go so far as to have suicidal thoughts or severe symptoms. Instead, they complain of symptoms that are often not easily associated with depression itself (chronic fatigue, physical complaints, apathy, asthenia, decreased libido, irritability, etc.).

The different forms of depression

The most common depressive disorders include major depressive disorder, persistent depressive disorder (dysthymia), and premenstrual dysphoric disorder. Another very common form of depression is postpartum depression, which affects women shortly after the birth of a child. The common feature of all these disorders is the presence of a sad mood, feelings of emptiness and irritability, accompanied by somatic and cognitive changes that significantly affect the individual’s ability to function. They differ in duration, timing, or presumed etiology (DSM 5, 2013).

Symptoms of depression

The symptoms of depression are varied and can be grouped into the following for ease of identification:

Cognitive symptoms of depression

  • A reduced ability to concentrate or make even small decisions, where there may be distractibility or memory problems.
  • A very strong tendency to blame oneself, to devalue oneself, to feel unworthy. Ruminations about small past mistakes are common, and neutral or trivial everyday events are interpreted as evidence of personal flaws or shortcomings.

Affective symptoms of depression

  • In general, people with major depression have a depressed mood, a marked sadness almost every day, so that mood and thoughts are always negative. There seems to be a real pain in life that leads to an inability to enjoy anything.
  • In fact, loss of pleasure in hobbies or activities that were once actively pursued is a common feature of depressive disorders. There may be social withdrawal, abandonment of pleasurable occupations, or decreased sexual desire.

Volitional/motivational symptoms of depression.

  • Marked fatigability, where the person feels exhausted and tired even in the absence of motor activity. The smallest tasks seem to require considerable effort, and there may be reduced efficiency in performing them (e.g., a person may complain that eating breakfast is tiring and takes twice as long as usual).

Behavioral symptoms of depression

  • Increased or decreased appetite. Some people with major depression report having to force themselves to eat. Others may eat more and have strong cravings for certain foods (e.g., sweets or other carbohydrates), as if seeking comfort in food.
  • An increase or decrease in sleep. Some people may wake up early, have frequent nighttime awakenings, or have trouble falling asleep and not feel rested in the morning (insomnia). Others may sleep too much (hypersomnia). Sometimes sleep disorders are the reason a person needs treatment.
  • A marked motor slowdown, which may manifest as increased slowness in doing things, speech, slowed thoughts, and body movements. Or, conversely, marked restlessness, in which there is an inability to sit up, walk back and forth, wring one’s hands, pull or rub one’s skin, clothes, or other objects.

Physical symptoms of depression

  • Headache, heart palpitations or tachycardia, muscle, bone, joint, and abdominal pain. People may feel dizzy or light-headed. Sometimes constipation or diarrhea may occur.

“Hidden” depression

In some cases, a person may experience only the physical symptoms of depression listed above, without being aware of his or her depressed mood.

If the somatic complaints are not due to trauma (accidents), disease, metabolic changes, or muscular strain, and the physician has ruled out any organic cause, this could be a condition called “masked depression. The diagnosis may be confirmed by the person’s positive response to antidepressant medication or by the presence of a family member who suffers or has suffered from major depression.

Subtle or subthreshold symptoms.

It is good to remember that the symptoms of depression can sometimes be so subtle that no one notices the problem, sometimes not even the person. The latter tends to attribute them to normal fatigue, stress, nervousness, or problems at work, in the family, or with couples.

In fact, it is quite common that the depressed person does not want to (or cannot) recognize his own internal state, which leads him to see “everything black”, to be intolerant, irritable, pessimistic, nervous, distant, and so on. He believes that it is only the consequence of external factors that should be changed (work, relationship, money, children, etc.).

All the symptoms of depression described above can occur acutely (with very acute and sudden phases of depression, which may disappear on their own or with therapy). Or they can be constant, though mild, with some sudden moments of deterioration. In this case, it is called dysthymia.

Spread and course of depressive disorder

Depression is twice as common in adolescent and adult females as in adolescent and adult males. In children, males and females are equally affected.

Depressive disorder can begin at any age, with an average age of onset around 25 years. Some have isolated episodes of major depression followed by many years without symptoms, while others have clusters of episodes, and still others have increasingly frequent episodes with increasing age.

Causes of depression

In general, the causes of depression can be grouped into three factors:

  1. Biological factors. These refer to changes in neurotransmitters, hormones, and the immune system. For example, changes in the regulation of neurotransmitters such as norepinephrine and serotonin, which alter the transmission of nerve impulses, can affect a person’s initiative, sleep, rumination, and interactions with others.
  2. Psychological and social factors. At the psychosocial level, stressful life events are well recognized as precipitating factors for depressive episodes. These include bereavement, interpersonal and family conflict, physical illness, life changes, being a victim of crime, and marital and child separation. We can also find changes in work conditions or the start of a new type of work, the illness of a loved one, serious family conflicts, changes in friendships, a change of city, etc. These events may have a greater impact on people who have had adverse childhood experiences and therefore lack the skills to deal with them effectively.
  3. Genetic and physiological factors. First-degree relatives of people with major depression are two to four times more likely to develop the disorder than the general population. What is genetically inherited is the predisposition to develop the disorder, not the disorder itself.

Depression treatment

Psychotherapy for depression

Hundreds of scientific studies have shown that cognitive behavioral therapy is the most effective way to treat depression. There are different types of psychotherapy, based on different schools of thought.

Without going into the specifics of the different approaches (e.g., systemic-relational, psychodynamic, or cognitive-behavioral), psychotherapy is a useful tool and has been shown to be effective in treating depression. In particular, many studies have shown that in many cases the combination of psychotherapy and medication has shown the best clinical results.

One role of psychotherapy is to work on a psychological level on different aspects related to depression, from the less observable and unconscious to the more conscious ones, such as the content of one’s thoughts, the management of daily life, important relationships and issues specific to the individual person.

Another important aspect is to gradually return to spending time on daily activities, especially those that are enjoyable. Devoting time to exercise, an old passion, self-care, or socializing can help improve mood and combat depression.

Cognitive interventions

Low mood affects thought processes, causing the person to see everything in black and white, as if they were looking at themselves, others, and the future through dark lenses.

Therefore, efforts are made to help the patient identify and modify the negative automatic thoughts that may support depression. For example, people tend to be hypercritical of themselves. Or they tend to blame themselves without evidence. Or they are more likely to notice negative events in everyday situations.

Therapy helps the person develop a more balanced and rational way of thinking. As a result, negative emotions subside and mood improves.

Rumination interventions

Numerous studies have shown that depressed patients tend to spend a lot of time brooding (or “ruminating”). In fact, their thoughts are too often focused on the past, on failures or setbacks, losses, grief, and mistakes. They think and rethink about what happened, blame themselves, wonder why, try to understand the reasons, or continue to search for solutions.

Rumination, however, tends to keep the mind focused on painful events, thereby increasing suffering. It does not allow attention to shift to the present and future, accepting what may have happened in the past. In essence, it fuels and perpetuates the depressive state.

In cognitive-behavioral therapy, we then intervene on beliefs about the rumination process itself, and then try to teach strategies for minimizing this dysfunctional mental activity.

Behavioral interventions

On the other hand, in the treatment of depression, people are helped to develop better coping skills to deal with daily difficulties. These are likely to have caused the person to become depressed.

For example, the person may be taught more effective ways of communicating (e.g., assertiveness) or strategies for solving problems in which he or she is involved (problem solving).

Treatment of depression also involves a gradual resumption of activities that have been abandoned (behavioral activation). Perhaps starting with those that the person once found most enjoyable (when he or she was not depressed). The therapist then invites the patient to actively plan his or her future days by incorporating small pleasurable or rewarding activities.

Cognitive behavioral therapy is thus very different from other types of psychotherapy: it focuses on the present, on the symptoms of depression, and tends to produce actionable solutions to the problems presented.

Mindfulness interventions

Mindfulness meditation has been shown to be particularly effective in preventing depressive relapse. It is therefore a recommended activity to be integrated into therapies, but not in the acute phase.

It cannot replace psychotherapy and/or drug therapies when a depressive episode is in progress, but it can be indicated as a strategy during intercritical periods. Of course, since it is a true discipline, it requires group learning and, above all, daily practice with continuity.

Medications for depression

The use of antidepressants is now widespread and has become one of the most widely used medications in medicine, but unfortunately the results are often modest and/or temporary.

Unless they are accompanied by sound psychotherapy that helps the person learn functional strategies for resolving acute depressive episodes and preventing relapse, it is highly likely that the person will experience recurrent relapses.

Several classes of antidepressants are used in the pharmacological treatment of depression:

  • serotonin reuptake inhibitors – SSRIs – (e.g., fluoxetine, fluvoxamine, paroxetine, sertraline, citalopram, escitalopram, buspirone);
  • tricyclic and tetracyclic antidepressants (e.g., desipramine, nortriptyline, maprotiline, chlorimipramine, imipramine, amitriptyline, nortriptyline);
  • norepinephrine serotonin multisystem agonists (e.g., venlafaxine, trazodone);
  • substituted benzamides (e.g., amisulpiride); noradrenergic system agonists (e.g., mianserin, mirtazapine, reboxetine);
  • methyl group donors (S-adenosyl-L-methionine).

All classes of drugs have been shown to be effective in treatment, although in the early forms, SSRIs are the most widely used because of their reduced side effect profile.

Other medications

In resistant forms, combinations with mood stabilizers (e.g., lithium, valproate, carbamazepine, oxcarbamazepine, gabapentin) and in some cases thyroid hormones may be used. When depressive episodes are one of the phases of bipolar disorder, stabilizing medications are the first choice.

A new molecule, agomelatine (Tymanax, Valdoxan), which interferes with melatonin and seems to have moderate efficacy on depressive symptoms, with fewer side effects than the other drugs mentioned above, has been on the market for a few years.

The use of antipsychotics in combination with antidepressants is justified in cases where the depressive picture is accompanied by psychotic symptoms, especially negative symptoms (e.g. affective flattening).


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