Depression

Depression.

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The word “depression” refers to a number of purely special terms that have gained widespread use also in non-professional environments (where this term sometimes sounds in vulgar-slang, warped forms: “I’m in depression” or even “in depression”, “he has a depression” etc.). Moreover, the conditions described by similar expressions, with real depression, as a rule, have little in common. Affective disorders have many facets and many names; depression itself can easily be confused with irritably-inflated dysthymia (“it’s not like that”), with viciously gloomy epileptic dysphoria, with apathy as a lack of drives and impulses, with abulia as a lack of will, with hypotension as a lowered mood background, and also with ordinary spleen , with a drunken or senile depravedness (“they do not deserve their due”), with cyclothymic mood swings, with poetic bright sadness or with anxious concern for tomorrow, with the husband’s reaction to the bumper rumpled by his wife or with the wife’s reaction to the “betrayal” of the husband who called five minutes later than usual. However, for simplicity, we all call this without thinking, depression, and we are understood. We are somehow constantly ready for depression – or fall into it, or share recommendations on how to get out of it. “You need to pull yourself together,” for example.

According to the generally accepted and most concise modern definitions, depression (in the medical sense of the word) is a mental disorder, the essence of which is to inhibit mental activity, mainly in its emotional-volitional components. Depression is a disease, it is in any case a pathological condition requiring special help, and not a normal variant. And even psychological reactions that are natural for a person to grief, difficult circumstances or a shock experienced by far are not always qualified in psychiatry as depression.

At the same time, depression is considered the most common psychiatric diagnosis and one of the leading causes of suicide, including attempts at true (not demonstrative-blackmail), completed (i.e. leading to the death of a suicide) and, worst of all, undertaken in adolescence or young age. The prevalence of clinically significant depressive register disorders is currently estimated at several hundred million people (!); in some categories of the population, the proportion of people suffering from some form of depression reaches one third, half, two thirds, three quarters …

In the meantime, unimaginable volumes of materials about depression are circulating in free Internet access, from very serious articles to “Five (seven, ten) interesting facts”, “Sensational discovery of Guinean scientists”, intriguing banners “How to get out without drugs in 5 minutes from protracted depression with the help of the usual … ”- and other textual consumer goods, fast food and second-hand goods of this kind. But even the most conscientious attempts at popular science coverage of the problem leave a mixed feeling: something is too simplified, but something, on the contrary, is unclear why it is becoming complicated; the emphasis is not on what should be emphasized; incorrectly used terms, drawn at random from the vocabulary of different scientific schools and directions … but in the end – somehow it all does not look like depression. Often you catch yourself thinking that the same is likely to be felt by any professional in any other field when confronted with IT interpretations of well-known problems; but nonprofessionals consume and take on faith just such information, information light (the author of these lines, for example, recently tried to master a simple building technology “over the Internet”, as a result of which he only suffered financial losses – and fell, of course, into depression) . What will be our combined view of the world if it is formed solely by the Internet?

If we turn to serious specialized literature, then here the volumes of published ones are surprising first of all. More than about depression, perhaps, only about schizophrenia has been written (with which depression in the clinic often has to be differentiated). At the same time, the observant ancient Egyptians and ancient Greeks, not to mention the father of medicine Hippocrates, were aware of the subtle nuances, symptoms and diagnostic signs of depression that not every intern doctor knows about and not every monograph mentions; or, say, ancient Arab healers – they tried to treat “melancholy” in a kind of hospital, for many centuries anticipating modern methodologies of the therapeutic environment, music therapy, etc. In general, than they did not try to treat depression, and with what they just do not try.

Acquaintance with any newest article, about a study, for example, of the normalizing effect of sleep deprivation on dopamine, serotonin and other neurotransmitters in patients with a depressive phase of bipolar affective disorder, causes a sensation of a different nature than mass web production. Sometimes one thinks, for example, about how right and accurate the ironic sage Stanislav Lem was when, in his Futurological Congress, he wrote about the total, helpless dependence of human consciousness, thinking, perception and mood on bioactive chemicals, microscopic concentrations of which are fully capable change (and replace) the subjective picture of the world. Or, re-reading the long lists of possible causes, risk factors, triggers of depression, you begin to frown involuntarily: this is one of those cases in medicine that we already know too much, incredibly much about these notorious “reliably significant causes and etiopathogenetic mechanisms”. So, we may not have seen the main and true reason yet. It may turn out that diseases of a caliber such as depression or the same schizophrenia are actually evolutionary diseases. Innumerable problems with the spinal column and lower extremities have become the price of upright posture and release of the hands; why not assume that a predisposition to depression is our payment for mental complexity, for the consciousness produced by society, for civilization and our own “I”. A fee for reason, in short. After all, the ancients warned us: the multiplying knowledge multiplies the tribulation; and our classic confirmed: grief from … what?

No, not everything is clear with the phenomenon of depression.

The reasons
So, depression is today considered by specialists as a polyetiological and multifactorial disease. In studies of etiopathogenesis, the role and specific “contribution” of burdened heredity, neurohumoral regulation disorders, somatic and concomitant mental illnesses, displaced childhood experiences and traumatic psychiatric situations in maturity, systematic overloads, deficiency of insolation and vitamin D, taking medications and fun potions like alcohol are being actively studied. disorders of thinking and the “cognitive map of the world”, etc.

The bioactive substances-neurotransmitters produced by the body are, in simple terms, a special group of hormones (although the mechanism of action is different), responsible for nervous activity, including higher. The theory that depression develops with an excess of some neurotransmitters and a deficit of others, for a long time dominated as the most logical, consistent, reasonable and, most importantly, consistent with the well-known principle of William Ockham, i.e. not requiring excessive complication and the introduction of additional explanatory constructs, when you can do with existing ones. Moreover, in numerous studies, this concept has been confirmed by experiments on animals (which, of course, have their own equivalents and forms of depressive disorders – unlike schizophrenia, again). However, to date, more and more analytical works are published, the authors of which conclude that the neurotransmitter theory of depression does not explain everything and is far from always confirmed, that is, it cannot be considered sufficiently reasoned or, at least, comprehensive.

Consequently, there are still many causes of depression; the amount of all possible combinations of them can be calculated only by the methods of statistical combinatorics, and which particular combination “detonates” in each particular case is unpredictable at the present stage of development of psychoneurology. In general, depression is more a group of diseases and psychopathological syndromes than a single disease.

In a number of cases, there are no apparent causes at all – obvious or at least presumptive – that could be considered as an etiological factor of a depressive disorder in a given patient. In general medicine, such diseases are called idiopathic, but in psychiatry the term “endogenous” is used – literally “occurring from the inside”, due to internal adverse conditions, processes and / or individual characteristics of a particular organism.

Symptomatology
At different time periods, many classifications of depression were proposed and applied (in scientific research, methodological developments, medical statistics, daily clinical work, official medical workflow, etc.). In turn, each of them reflected the existing at that time representations, traditions of the national psychiatric school, the views of the author, and included many types of this disorder: depression is sad, anxious, reactive, neurotic, somatized, and somatogenic (resp., Manifested by bodily and physiological disturbances or caused by them), apathetic, adynamic, apathetic-adynamic, anxious-dreary, etc .; depression with hypochondria, paranoid, nihilistically delusional, hallucinatory inclusions; by type of course – recurrent, single episode, bipolar disorder … By the way, the latter disease refers to the so-called “Big Psychiatry”, which is still often called the obsolete name of “manic-depressive psychosis” and is characterized by a cyclical change of clearly defined clinical phases – excitement and depression, often depending on the time of year.

Many prominent researchers have also dealt with the problem of atypical depression (ironic, smiling, depression without depression, latent, larvated, masked, etc.).

Many attempts have been made to isolate pathognomonic, i.e. a symptom complex inherent in any depression (and not inherent in any other disease) – scientists and clinicians were looking for various “purely depressing” triads, notebooks, constellation of symptoms, and this would really be of great importance for the diagnosis, treatment and understanding of depression in general.

The fundamental, basic ideas about depressive symptoms remain basically the same. Depression of higher nervous activity is manifested by persistently depressed mood, decreased activity (including speech) and productivity (including intellectual, which does not mean dementia or the breakdown of the structural logic of thinking), inhibition, weakening or a complete lack of interest in what is happening. Quite typical are vital (vital) longing, anxiety and fear of the future, “heaviness” or “stone” in the chest, abdomen, soul, head, etc .; loss of goals and meaning of existence, suicidal thoughts, sometimes obsessive, and suicidal actions – either because of a sense of meaninglessness of further life, or with the motive “to stop unbearable torment in one fell swoop” (in many cases, depressive experiences are really very difficult and do not fit into the usual the expression “twists himself”); excruciating guilt, low self-esteem, self-image as a burden for others, and about one’s own painful condition as a well-deserved punishment. Almost always, to one degree or another, anhedonia is present — the inability to receive joy and pleasure from all that used to please; loss of colors of the world. Many patients complain that they cannot hold back tears – with or without; in more severe cases, patients, on the contrary, cannot cry (“everything seems to be cemented inside”), describe an extremely painful feeling of the absence of any emotions (the so-called mental anesthesia). Symptoms such as dyssomnia (sleep disturbances, for example, intermittent sleep, difficulty falling asleep, sudden waking up, lack of alertness in the morning) or insomnia (persistent and almost complete insomnia), changes in appetite (a sharp increase, or more often decrease: “you have to force yourself”, “food is tasteless like grass”), a sharp weakening or complete absence of sexual desire, decreased potency in men, dysmenorrhea or amenorrhea in women. The Protopopov triad has not lost its significance: mydriasis (dilated pupils), tachycardia (accelerated heartbeat) and a tendency to constipation. In addition, many patients with severe endogenous depression have a tendency to dry skin, hair loss, brittle nails, drying out the tongue (Osipovs symptom).

In general, it is probably impossible to list all the known, observable, observable, recorded by psychiatrists and pathopsychologists symptoms of depression. However, it is worth adding that not a single symptom and not a single depressive symptom complex has yet become a universally recognized pathognomonic key.

Diagnostics
The main diagnostic tool of psychiatry is the clinical and psychopathological method, which includes a thorough study of the anamnesis, a conversation with the patient and, separately, with his immediate family, a comparison of subjective complaints (or their absence, which is also not uncommon) with available anamnestic information, and observations of middle and junior staff for patient behavior (if the patient is hospitalized); analysis of facial expressions, speech (pace, content, vocabulary, focus, the ratio of spontaneous and reflected speech, the logical and semantic adequacy of judgments and many others), the degree of criticality of the patient, the dynamics of the state during therapy. In many cases, it is advisable, very informative (in terms of assessing the state of basic mental functions) and therefore an experimental-psychological examination is necessary.

Of great importance in the diagnosis of depression – and in modern medicine in general, especially in the disciplines of the neuropsychiatric direction – are clinical scales. They are a form with a list of symptoms, signs, significant phenomena, the severity of each of which the doctor evaluates in points, or, in a questionnaire-questioning version, the patient evaluates. The total amount, as well as the amounts for individual groups or headings, allows us to judge the severity of the condition and the structure of symptoms (for example, the dominant experiences – longing, anxiety, fixation on health, etc.). One of the first such scales, which became widespread throughout the world, was the Hamilton scale (1960) – an extensive, detailed and including many psychopathological phenomena. It is applied to this day; at the same time, many other tools of this kind have been developed, more compact and to some extent reflecting the pathomorphism of depression (pathomorphosis is a tendency to change the typical clinical picture of the disease over time).

However, it should be noted that the use of such formalized diagnostic tools, indispensable in large-scale scientific or screening studies, in the clinic can lead precisely to formalism, to underestimation of purely individual characteristics and nuances. Therefore, the final clinical diagnosis is never established on the basis of just a scale or questionnaire: in all cases this is a serious painstaking work of the attending physician, requiring consideration of a mass of factors and indicators, and sometimes a collegial clinical analysis or a cathedral consultation.

Recently, in publications, including domestic, the question of diagnosis, or rather, the recognition of depression (especially atypical or dissimulated, that is, deliberately hidden by the patient for one reason or another) is raised in terms of shifting the model of medical care to outpatient forms. A general practitioner really should be well prepared for the fact that a depressive disorder, with significant severity, can be hidden behind purely therapeutic (gastroenterological, cardiological, etc.) complaints, especially if they are not confirmed by objective studies, and this is not a simulation, not aggravation (exaggeration of symptoms) and not an attempt to fulfill the need “at least for someone who listens, understands and talks” (and sometimes it looks like that). Depression is many-sided, volatile and insidious, but, we repeat, in any case, it is subject to medical intervention: its absence can end very sadly.

Treatment
Traditionally, there are many publications on the role of psychotherapy and social therapy in the treatment of depression. Cases are reported when the patient was able to be cured without the use of pharmacotherapy or even against the background of its inefficiency. Other non-drug methods are widely practiced: deprivation (deprivation) of sleep, numerous physiological and acupuncture techniques, transcranial magnetic stimulation, craniocerebral hypothermia, etc.

However, severe, psychotic or subpsychotic levels, depression today is treated worldwide with antidepressants. To date, several generations of these drugs have already been replaced, and their individual groups have been developed that allow targeted elimination of certain dominant symptom complexes. Like all other medicines, of course, not even the latest antidepressants are absolutely safe; the potential danger increases hundredfold when trying to self-designate and self-medicate – this can not be done categorically. The treatment of depression is the exclusive competence of certified and certified psychoneurological specialists, and only a doctor can prescribe antidepressants (as well as monitor their effectiveness, change the regimen, etc.).

At the same time, the role of the psychotherapeutic effect provided by the attending physician is truly enormous. The confidence in healing that he instills, detailed explanations of the ways and methods of treatment, anti suicide work, deactivation of all kinds of prejudices and painful ideas are extremely important in the treatment of depression, no matter what treatment regimen is carried out (not all, but very many cases do without hospitalization) and in whatever form depressive disorder occurs.