Medicine

Recognising Depression

A short exploration and analysis of depression, influenced by recent suicides of high profile celebrities including Chester Bennington.
 

In light of the recent and alarming suicides among middle aged men, particularly celebrity musicians that seemed to stop the world for that day; and of whom most notably Chris Cornell of SoundGarden + Audioslave, and Chester Bennington of Linkin Park, both being high profile artists that helped shape the voice of their generation, are now seen as victims of this male depression. We do not know the full circumstance surrounding their actions, yet there are those who see fit to condemn it entirely. Personally, I think to judge on misinformation or/and lack of information is in poor taste. After all, S. Freud, the father of modern Psychiatry was the one to spearhead the core concept of all psychiatry; that mental illness stems from an organic cause. The bio-psycho-social model of mental illness suggests that neuroses and psychoses can be either of a biological cause (genetic), a result of a psychological event (mental and/or emotional trauma) or as a result of poor social support; or even a combination of all 3. Those who looked into Chester's past would be aware of his history of abuse which he confessed in multiple interviews.

Bennington was molested from the age of seven until he was 13 by a friend who was a few years older than him.

‘I was getting beaten up and being forced to do things I didn’t want to do. It destroyed my self-confidence.

‘I didn’t want people to think I was gay or that I was lying. It was a horrible experience.’

Chester has never identified his abuser.

Read more: http://metro.co.uk/2017/07/21/chester-bennington-was-molested-aged-seven-by-an-older-friend-6796146/#ixzz4nW1nQs6Q

He also was a known drug user in his teens which continued well into adulthood.

Speaking to Metal Hammer, Chester said: ‘I was on 11 hits of acid a day. I dropped so much acid I’m surprised I can still speak! I’d smoke a bunch of crack, do a bit of meth and just sit there and freak out.

‘Then I’d smoke opium to come down. I weighed 110 pounds. My mom said I looked like I stepped out of Auschwitz. So I used pot to get off drugs. Every time I’d get a craving, I’d smoke my pot.’

He continued: ‘In 2006, I had a choice between stopping drinking or dying. I did some counseling with the guys and they really opened up and told me how they felt. I had no idea that I had been such a nightmare.’

Read more: http://metro.co.uk/2017/07/21/chester-bennington-was-molested-aged-seven-by-an-older-friend-6796146/#ixzz4nW34rB9R

Also it is no secret that those in the entertainment business tend to have a higher occurrence of Bipolar disorder. Z. Janka and H.Orvosi concluded:

Comparing to the general population, bipolar mood disorder is highly overrepresented among writers and artists. The cognitive and other psychological features of artistic creativity resemble many aspects of the hypomanic symptomatology. It may be concluded that bipolar mood traits might contribute to highly creative achievements in the field of art. At the same time, considering the risks, the need of an increased medical care is required.

http://europepmc.org/abstract/med/15462476

This makes sense as artists typically have concerts, interviews and events multiple times per day. To find the energy demanded by the industry usually is found during manic phases of Bipolar disorders. Before Linkin Park's tour was cancelled on the 21st of June, 2017, their website revealed a concert virtually every day from June to October, including even as far east as Japan. This alludes to the mental and physical stresses musicians endure as traveling can leave little time for appropriate rest and recovery.

It is not certain whether the celebrities in question were bipolar specifically.

How this percolates to the common man can be partly explained by the social stigma involved with depressive disorders. Patients tend to be defensive, suspicious and even apprehensive towards family, friends and health workers and because of this, 60% of all cases go undiagnosed (Source: Medscape, 2017). In Jamaica, as much as 80% of women in particular with depressive disorders, are suspected to remain undiagnosed. Such a formidable barrier can prove most difficult in treatment delivery, though music and literature may penetrate in some cases easier than a person can. When these musicians and artisans die, it creates a cathartic state of loss as this unique window into their consciousness may now shut close. It is particularly devastating when we learn the inner suffering in the lives of these artists, who directly or indirectly helped us in some way. This was seen in the shocking suicide of Robin Williams. A household name whose long career was built on entertaining and elevating the moods of an international audience. Some would see this as the ultimate sanction of the victim (Atlas Shrugged - Ayn Rynd). To quote Tolkein's Aaragorn :

"I give hope to men.. I keep none for myself"

With all this in consideration, though, it becomes clear the need to recognize depression and intervene appropriately within a timely manner to reduce its progression and reverse its effects where possible. Though, above all, understanding depression for both ourselves and for the patient as a potentially treatable entity, should always be at the core of our thoughts.

What is depression?

Depression 1991-2006



Over the decades depression has remained fairly constant. A rise in female suicide is noted in most recent years.

Depressive disorders include:

  • Disruptive mood dysregulation disorder
  • Major Depressive Disorder (including Major Depressive Episode)
  • Persistent Depressive disorder (dysthymia)
  • Premenstrual dysphoric disorder
  • Substance/medication-induced depressive disorder
  • Depressive disorder due to another medical condition
  • Other specified depressive disorder
  • Unspecified depressive disorder

They are all linked by the feeling of sadness and/or irritable with accompanying somatic (body changes, see clinical presentation) and cognitive changes (conscious intellectual activity) that significantly reduces the patient's daily function. How they differ depends on:

  • Duration
  • Timing
  • Underlying cause

Disruptive mood dysregulation disorder was added to the DSM5 to represent children under 12 years of age with these symptoms. The separation is to acknowledge that these children develop a unipolar depressive disorder or anxiety disorders rather than bipolar disorders.

Major Depressive Disorder represents the classic condition in this group. It is characterized by discrete episodes of at least 2 weeks duration (most last longer) which involved clear cut changes in affect (outward display of emotions), cognition (higher mental functioning) and neurovegetative functions as well has having remission in between episodes. One episode is sufficient for diagnosis though its expected that most are recurring.

Persistent Depressive disorder (dysthymia) is new to the DSM5 and represents the DSM4 classic criteria for Chronic Major Depression and Dysthymia. It is a form of depression that includes mood disorders of more than 2 years in adults, and more than 1 year in children.

A large number of medications and drugs are associated with depressive disorders.

Major Depressive Disorder (MDD)

There are 5 criteria upon which the patient must meet for MDD to be diagnosed. A,B,C,D and E.

A

Five or more of the following symptoms are present during the same 2 week period and represent a change from previous functioning where at least one of the symptoms are:

  • Depressed mood
  • Loss of interest or pleasure

Note: Cannot consider these symptoms if they are linked to another condition

  • Depressed Mood: Most of the day and nearly every day. Can be reported subjectively or by observation. Children and adolescents can be irritable as well.
  • Diminished Interest/pleasure: All or in almost all activities (reported subjectively or observed)
  • Weight change: Significant weight loss (when not dieting etc) or weight gain. (>5% body weight in a month) or decrease in appetite virtually every day. (Children may be low weight for age)
  • Sleep change: Insomnia or hypersomnia virtually every day
  • Behavior Change: Psychomotor agitation or retardation virtually every day (observed by others only)
  • Altered Energy: Fatigue or loss of energy virtually everyday
  • Self Esteem: Feeling of worthlessness, excessive or inappropriate guilt (may be delusional) virtually every day. Must be differentiated from guilt based on illness itself or by self reproach (blame).
  • Change in cognition: Diminished ability to think or concentrate, indecisiveness virtually every day (subjectively reported or observed)
  • Thought content: Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or suicide attempt or a specific plan for committing suicide.

B

  • Symptoms cause clinically significant distress, social, occupational or other important impairment.

C

  • Symptoms not attributable to any physiological effect, substance or medical condition.

Criteria A-C represent a major depressive episode

Bereavement, loss of significant possessions, severe medical conditions etc can cause similar symptoms but are considered appropriate to the circumstance. Normal responses to significant loss should always be considered. The final decision will depend on the patient's history and the cultural norms for expression of the patients' distress. Physiological grief is expected to reduce within weeks and comes in waves known colloquially as the "Pangs" of grief. They are associated with thoughts of the loss itself (relative etc) where as MDE is not tied to any particular thought or preoccupation. MDE is also associated with pessimistic and self-critical ruminations. Self loathing and feelings of worthlessness are common in MDE but self esteem is generally preserved in typical grief.

D

  • The occurrence of a major depressive episode (MDE) is not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder or other specified and unspecified schizophrenia spectrum and other psychotic disorders.

E

  • There has never been a manic or hypomanic episode!

ICD Coding

Depends on whether the disorder is single or recurring, severity, presence of psychotic features and remission status. The full list can be found in the DSM5, page 162 under Depressive Disorders.

Pathophysiology

Uncertain though, a complex interaction between neurotransmitter availability and receptor regulation is implicated. Disturbance in serotonin activity is an important factor as evidence by treatment with SSRI (selective serotonin reuptake inhibitors which prolong its effect) . Though raising neurotransmitters alone do not have the same efficacy long term as antidepressants do (eg cocaine use).

Sunlight exposure may have a role as seasonal depression (seasonal affective disorder) occurs in the winter months of least sunlight.

Vascular lesions may also disrupt neuronal networks involved in emotion regulation, particularly the frontostriatal pathways that link the dorsifrontal cortex, obitofrontal cortex anterior cingulate and dorsal cingulate.

Frontostriatal Pathway



Structurally, decreased metabolic activity in neocortical structures and increased metabolic activity in the limbic structures are observed. these structures are known to have serotonin receptors. These effects are also seen in aging.

Diagnostic Features

Symptoms must be present virtually everyday with the exception of weight change and suicidal ideation. Depressed mood must be present for most of the day and present nearly every day.Usually the presenting complaint isn't depression but insomnia and fatigue so depressive potential must be probed to prevent under-diagnosis. Sadness may be denied but may be observed during interview. Psychomotor and delusional symptoms are not as common but represent a greater severity.

The essential feature of MDD is a period of at least 2 weeks here there is either depressed mood or loss of interest/pleasure in nearly all activities (criteria A). At least 4 other symptoms mentioned above must be present. For a symptom to be considered "present", it must be newly observed/reported or worsened significantly from the pre-episode status. Symptoms must persist for most of the day in this time and must be accompanied by a decrease in function in some significant form. Milder forms may preserve function but would require significantly more effort.

Here we can see that in this interview in the first few minutes, Chester is confessing a chronic course of his depression which is not tied to any specific entity or experience:







There is significant loss of interest, particularly in fields which used to fulfill them. This is noticed usually by those close to them. There is social withdrawal and neglecting these activities.

Appetite can change by either increasing or decreasing. Some admit to having to force themselves to eat, while others crave specific foods, usually carbohydrates and sweets.

Sleep alteration can take the form of excessive sleeping or insomnia. Insomnia is usually middle insomnia (waking up in the night and difficulty falling asleep), or terminal insomnia (waking too early and unable to fall back asleep). Initial insomnia (difficulty in falling asleep may also occur). Hyperinsomnia would present with daytime sleeping and can be the presenting complaint.

Psychomotor changes can be symptoms of agitation or retardation. They may report fatigue without physical exertion and normal tasks may require significantly more effort and time.

Their decreased self worth and self esteem causes an interpretation of trivial day-to-day events as evidence of personal defects and their sense of responsibility of untoward events are exaggerated. It may be inflated to the point of delusion, eg. they may believe that they are the cause of suffering in the world.

They may report an impairment to think, concentrate or make minor decisions and complain of being easily distracted. Children may have a precipitous drop in grades and elderly may be misdiagnosed with dementia (pseudodementia).

Treatment usually fully restores memory and cognition.

Thoughts of suicide, death, and attempts of suicide are common. It is a red flag for a known patient to have been putting affairs in order concerning death such as their Will, unsettled debts etc. It is also a red flag if they have obtained means to perform suicide, such as buying rope, a gun, poison and have spoken about a time and/or place to perform it.

Clinical Presentation

Patient may range from completely seeming asymptomatic to mute, avoidant and catatonic. Hygiene may also be poor in severe cases.

Screening Instruments

Self-report screening instruments for depression include the following:

  • Patient Health Questionnaire-9 (PHQ-9): A 9-item depression scale; each item is scored from 0-3, providing a 0-27 severity score. - most used
  • Beck Depression Inventory (BDI) or the Beck Depression Inventory-II (BDI-II): 21-question symptom-rating scales providing a 0-63 severity score.
  • BDI for primary care: A 7-question scale adapted from the BDI.
  • Zung Self-Rating Depression Scale: A 20-item survey.
  • Center for Epidemiologic Studies-Depression Scale (CES-D): A 20-item instrument that allows patients to evaluate their feelings, behavior, and outlook from the previous week.

Associated Features Supporting Diagnosis

MDD is associated with a high mortality, but not just due to suicide. Patients with MDD have a substantially higher risk of dying if admitted in a nursing home in the first year than those without. Other symptoms that may be found are tearfulness, irritability, brooding, obsessive rumination, anxiety, phobias, excessive worry over physical health, complains of muscle and join paint etc. Children may present with separation anxiety.

Unfortunately despite the extensive documentation of the neuroanatomical, neuroendocrinological and neurophysical correlates of MDD, there is no specific lab test with a high enough sensitivity and specificity yet. A link was found with MDD and hypothalamic-pituitary-adrenal axis hyperactivity and is being researched.

Prevalence

7% of people in the US have MDD with a risk 3 times higher in the age 18 - 29 category, than those greater than 60 years. Females are 1.5 - 3 times more likely than males in adolescence.

Development and Course

Can appear at any age, but increases after puberty and peaks in their 20's. Some individuals experience virtually no remission while others can be in remission for years before another episode. Chronicity increases the likelihood of underlying personality, anxiety and substance use disorders, and decreases the likelihood that treatment will be followed by full symptom resolution.

Recovery occurs within 40% of individuals within 3 months of symptoms, and 80% by 1 year. Risks of poor recovery include psychotic features, prominent anxiety, personality disorders and symptom severity, and increases the longer the symptoms linger for. It is also raised in those with previous severe episodes, and those with multiple previous episodes.

Initial presentation may mimic the depressive phase of bipolar disorder, but eventually a manic phase will reveal itself and a bipolar diagnosis can be considered. It is more likely in adolescence, those with psychotic features and those with a family history of bipolar disorder.

MDD with psychotic features may herald the transition into schizophrenia.

There is no different response in treatment based on age and gender. Symptom differences do exist in age though, as hyper/hypoinsomnia exist more in the younger groups while melancholic symptoms and psychomotor disturbances are more common in older patients.

Risk of suicide decreases during middle age and in the elderly but is not eliminated. Depressions with an earlier onset are likely to include personality disorders. The course does not change with aging.

Risk and prognostic Factors

  1. Temperamental

    • Neuroticism (negative affectivity) is a well established risk for MDD as a response to stressful events.
  2. Environmental

    • "Adverse childhood experiences, particularly multiple experiences of adverse types constitute a set of potent risk factors for MDD" - DSM 5, page 166.
  3. Genetic and Physiological

    • Those with a family history of MDD have a twofold higher risk of developing MDD. It is usually the early onset type and is recursive. Approximately 40% inherited.

Course Modifiers

All major non-mood disorders increase the risk of getting depression. MDE that follows the background of another condition are often refractory (substance use, anxiety and borderline personality disorders). It may also obscure identification. Chronic or disabling medications also increase the risk for MDD. Those with diabetes, cardiovascular disease and morbid obesity are more likely to become chronic than are depressive episodes in medically healthy individuals.

Culture-Related Diagnosis Issues

The majority go unrecognized in primary care, somatic symptoms are likely to be the presenting complaint.

Gender Related Diagnostic Issues

Occurs in famles more but no difference in symptoms, course, treatment and response between male and female. The risk of suicide attempts in females are higher, but risk of suicide completion is lower.

Suicide Risk

The risk is present at all times during MDD but is more likely with previous attempts or threats. Though, suicide completions are mostly not preceded by a first attempt. Risks of suicide completion is associated with the male gender, being single, living alone and having permanent feelings of hopelessness. The presence of Borderline Personality Disorder markedly increases the risk for future attempts.

Functional consequence of MDD

Depends largely on severity of symptoms. Patient may range from appearing completely normal outwardly, to completely incapacitated such as mute or catatonic and unable to complete basic self care/hygiene. There is a general increase in experiencing pain and physical illness, and a decrease in phsyical, social and role functioning.

Differentials

  • Manic episodes with irritable mood or mixed episodes

    • MDE with irritation may be difficult to distinguish from manic episodes with irritable mood, or mixed episodes.
  • Mood disorder due to another condition

    • MDE is the correct diagnosis if the mood disturbance is found to not be directly caused by history, examination and lab findings.
  • Substance induced depressive or bipolar disorder

    • Distinguished from MDE if the offending substance is found to cause symptoms and mood disturbance. eg cocaine withdrawal.
  • Attention deficit/hyperactivity disorder

    • Distractibility and low frustration tolerance occur in both this and MDE. Overdiagnosis in children is possible.
  • Adjustment disorder

    • MDE that occurs as a response to a psychosocial stressor is distinguished from adjustment disorder by the full criteria of MDE not being met.
  • Sadness

    • Inherently a human experience, and should not be considered MDE unless criteria are met.
  • Medical

    • CNS diseases
    • endocrine disorders
    • infectious and inflammatory diseases
    • sleep-related disorders.

Comorbidity

Frequently found with:

  • Substance related disorders
  • panic disorder
  • obsessive compulsive disorder
  • anorexia nervosa
  • bulimia nervosa
  • borderline personality disorder

Management

Combined therapy involves the quickest recovery.

Treatment modalities include:

  • Pharmacological

    • SSRI
    • SNRI
    • Atypical Anti depressants
    • Tricyclic antidepressants (TCA)
    • Monoamine oxidase inhibitors (MAOI)
    • St. Johns wort
  • Psychotherapy

    • Interpersonal psychotherapy (IPT)
    • Cognitive-behavioral therapy (CBT)
    • Problem-solving therapy (PST)
    • Behavioral activation (BA)/contingency management
  • Electroconvulsive therapy

    • Electroconvulsive therapy (ECT) is a highly effective treatment for depression.
  • Stimulation

    • Vagus nerve stimulation
    • Transcranial magnetic stimulation

Conclusion

It is important to differentiate between appropriate grief and a disorder of organic cause. It is unfair to judge patients with disorders under the lens of a normal healthy adult. Their actions may not necessarily be their true intention as psychotic symptoms and delusions may be present in depression disorders. Negative social stigma has resulted in a significant part of the population being underdiagnosed and symptoms often progress, recur and are found to be refractory. Treatment is manifold and be encouraged as well as a strong social support to counteract the associated negativity of mental illness.

Sources:

http://emedicine.medscape.com/article/286759-overview#a2

http://dsm.psychiatryonline.org/pb-assets/dsm/update/DSM5Update2016.pdf

http://metro.co.uk/2017/07/21/chester-bennington-was-molested-aged-seven-by-an-older-friend-6796146/#ixzz4nW34rB9R

http://europepmc.org/abstract/med/15462476