Psychosocial causes
DEPRESSION
Dr. L.R. KHAN
Consultant Psychiatrist, Aurangabad

INTRODUCTION :
Mood refers to the internal emotional state of an individual and effect, to the external expression of emotional content. Mood may be normal, elevated, or depressed. A normal individual experiences a wide range of moods and has a equally large repertoire of effective expression, he feels in control of his moods and effects. Patients with depressed mood show loss of energy and interest, guilty feelings, dificulty in concentrating, loss of appetite, decreased sexual activity. This disorder virtually always results in impaired inter-personal, Social and occupational functioning.

The lifetime expectancy of developing depression is approcimately 20 percent in women and 10 percent in men. It is estimated that only 25 percent of those who meet the criteria for major depression receive treatment. An almost universal observation, is the two fold greater prevalence of depression in women than in men. The reasons may include varying stresses, child birth, learned helplessness, and horminal effects. The onset of depression occurs from childhood to sensecence. The prevalence of mood disorder does not differ from race to race. In general depression occur more often in persons who have no close interpersonal relationship, who are divorced or separated. There is no corelation between social class. Recent immigration may be positively correlate to depression.

CAUSES
Causes of depression can be divided into categories, biological and psychosocial.
BIOLOGICAL CAUSES:
There is data to indicate that dopaminergic activity may be reduced in depression. Abnormalities of sleep architecture are among the most robust biological markers of depression. There is increased early morning awakening and discontinuity of sleep with multiple awakenings during the night. Abnormalities in immune function have been reported in depression. It has been hypothesized that depresion is disorder of chronobiological regulation.Positron emission tomographic (PET) scan have suggest reduced brain metabolism,and other studies detected reduced cerbral blood flow in depression,particularly to the basal ganglia. Single study of computed tomographic EEG in depression found abnormalities.

Genetics
Approximately 50% of depression of patients have at least one parent with depression.if one parent has depression there is 25% chance that any child will have depression.Adoption studies have shown that the biological parents of adopted depression children have an incidence of depression similar to that of the parents of nonadopted depression chlidren. The incidence of depression in the general in the adoptive parents is similar to the baseline incidence of depression in the general population. Twin studies have shown a concordance rate of 0.67 for depression in monozygotic twins and 0.02 for depression in dizygotic twins.

Psychosocial causes
Most clinicians believe that there is a relationship between stressful life event ane clinical depression.
Lack of care for food,shelter or clothing and need for diagnostic procedures are clear indications for hospitalization.A history of rapidly progressing symptoms and rupture of the usual support systems are also indication for hospitalization.
Following points must be remembered about treatmant of depression.
*Acute depression is treatable condition in 75% of patients.
*Depression is a combination of biological and pyschological factors,both of which benefit from drug theropy.
*The patient will not get addicated to antideressionts since these drugs do not give immediate gratification.
*It may take 3 to 4 weeks for the patient to feel the antidepressant's sffects; and even if there is no improvement at that time,there are many other medications to try.
*Sleep and appetite will improve first followed by a sense of returned energy;the feeling of depression will be the last symptom to change.
*The best reson for choosing a particular drug is a past history of response to that agent in the patient or a family member.
*A complete trial of an antidepressant should last for about minium of 4 weeks at maximum dose.
*ECT is the most effective antidepressant treatment and is indicated when a rapid therapeutic is particularly desirable( E.G. high suicide risk,)
*Antidepressant treatment should be maintained for at least 6 months or the length of a previous episode,which ever is greater.

Psychoterapy should be integrated with drug treatment in these patients.Studies have indicated that psychotherapy in combination with antidepressant is more efficacious than either method alone.

Intepersonal therapy (IPT) is short-term psychotherapy.It is characterized by an active, therapeutic approach and an emphasis on the patient's current issues and social functioning.Discreta behaviors,such as lack of assertiveness, social skills, or distorted thinking may be addressed but only in the context of their meaning or effect on in-terpersonal relationships.

The cognitive theory of depression points that congnitive dysfunctions are the core of depression. The signs and symptoms of depression are hypothesized to be consequences of the congnitive dysfunctions. The goal of cognitive therapy is to alliviate depression and to prevent its recurrence by helping the patient to identify and test negative ways of thinking and to rehearse new cognitive and behavioral responses.

Several behavior therapies have been developed for the treatment of depression. The treatment program is highly structures and generally short term. The principle of reinforcement is seen as the key element in depression. Changing behavior is considered to be the most effective way to alliviate depression.

Family therapy is indicated in cases where (1) The patient's depression appears to be socially jeopardizing that person's marriage and or family functioning or (2) An individual's depression appeared to be prompted and maintained by marital and or family intersection patterns. Family therapy examines the role of the depressed member in the overall psychological well being of the whole family, role of the entire family in the maintenance of the depression.
(Author is Consultant Psychiatrist at Raahat Hospital, Aurangabad.)