REVIEW OF LITERATURE: INTRODUCTION Depressive disorders are characterized by a depressive mood (e.g., sad, irritable, empty) or loss of pleasure accompanied by other cognitive, behavioral, or neurovegetative symptoms that significantly affect the individual’s ability to function. (7) Depressive disorders can take many forms, depending on their severity and chronicity. The disorder mostly associated with “classic†depression is major depressive disorder, and this is the disorder most often referred to when someone reports that they suffer from depression. Major depressive disorder (MDD) (unipolar depression) is reported to be the most common mood disorder. It may manifest as a single episode or as recurrent episodes. Major Depressive Disorder has been ranked as the third cause of the burden of disease worldwide in 2008 by the WHO, which has projected that this disease will rank first by 2030. (8) The main feature of major depressive disorder is the occurrence of at least one episode of major depression, which is significant depressive symptoms that last for a significant period of time. DIAGNOSTIC CRITERIA According to DSM-5, diagnostic criteria of Major depressive disorder are as following (9): A. Five or more of the following symptoms that have been present during the same 2- week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure 1. Depressed mood 2. Markedly diminished interest or pleasure in all or almost all activities 3. Significant weight loss or weight gain 4. Insomnia or hypersomnia 5. Psychomotor agitation or retardation 6. Fatigue or loss of energy 7. Feeling of worthlessness or excessive or inappropriate guilt 8. Diminished ability to think or concentrate, or indecisiveness 9. Recurrent thoughts of death, recurrent suicidal ideation B. Symptoms cause clinically significant distress or impairment in social, occupational, or other areas of functioning. C. The episode is not attributable to the physiological effects of a substance or another medical condition. D. At least one major depressive episode is not better explained by schizoaffective disorder and is not superimposed on schizophrenia, schizophreniform disorder, delusional disorder, or other specified and unspecified schizophrenia spectrum and other psychotic disorders. E. There has never been a manic episode or hypomanic episode. Major depressive disorder may be present with psychotic features, melancholic features, atypical features, catatonic features and seasonal pattern. (10) RISK AND PROGNOSTIC FACTORS Temperamental Environmental Genetic and physiological Course modifiers (9) RATING SCALES FOR DEPRESSION (2) (10) Clinician administered scale- the Hamilton Rating Scale for depression (HRSD) and Montgomery-Asberg Depression Scale (MADRS) particularly useful in patients with melancholic depression. Self administered scale-The Zung self-Rating Depression Scale, The Beck depression scale, Geriatric depression scale (GDS), The Raskin Depression Scale, Center for Epidemiological Studies- Depression Scale (CES-D) COMORBIDITY Major depressive disorder frequently co-occurs with substance-related disorders, panic disorder, GAD (generalized anxiety disorder), PTSD (post traumatic stress disorder), OCD (obsessive compulsive disorder), anorexia nervosa, bulimia nervosa and borderline personality disorder. (9) DIFFERENTIAL DIAGNOSIS(9)(10) Manic episodes with irritable mood or mixed features Bipolar disorders Depressive disorder due to another medical condition Substance/ medication induced depressive disorder Persistent depressive disorder Premenstrual dysphoric disorder Disruptive mood dysregulation disorder Schizophrenia Attention-deficit hyperactivity disorder Adjustment disorder Bereavement Sadness Dementia Parkinson disease MAJOR DEPRESSIVE DISORDER IN GERIATRIC AGE: In India, elderly or senior citizens have been defined in the National Policy for Older person 1999 as people with an age more than 60 years. (1) Depressive symptoms are present in about 15 percent of all community residents and nursing home patients. (10) Older people are particularly vulnerable to major depressive episodes with melancholic features. Major depression manifests somewhat differently in older compared to younger adults. Physical symptoms such as changes in appetite and body weight, constipation, and sexual dysfunction are more common in older adults; on the other hand, the physical symptoms in older adults could be a result of an undiagnosed physical illness. Depressive symptoms are common among older adults and are associated with functional impairment and decline, mortality, increased service utilization, and decreased quality of life. Risk factors and correlates of depression in late life: Being widowed or otherwise unmarried, impaired functional status, impaired social support, perceived loneliness, perceived poorer health, low internal locus of control, family history of depression, fewer years of education, living in an urban area, lower socioeconomic status, having one or more chronic physical illnesses, experiencing other recent stressful events. (2) Psychological aspect: (11) Old age carries special risks, not the least of which is poverty and fixed income. In addition, the aging body is highly vulnerable to disease. In the elderly, bleak circumstances and the internal state that Erikson referred to as despair can combine to make life seem not worth living and can produce psychological disturbances, including depression severe enough to provoke suicide. This happens especially to elderly people who are enfeebled and dependent at home or on nursing facilities that give little reinforcement for responsive, adaptive behavior. HOMOEOPATHIC APPROACH As per Dr. Hahnemann, mental diseases are one-sided diseases of chronic type affecting the whole psychosomatic entity, which manifest most of the symptoms on the mental aspect of the human organism. (Aphorism 210) (12) Some of the homoeopathic medicines that are important for themanagement of depression from the homoeopathic repertory by William Boericke under mind, mood, disposition, melancholic, despondent, depressed, low spirited, gloomy, apprehensive, “blues†are Anacardium, Arsenic, Aurum met, Cimicifuga, Conium, Cyclamen, Ignatia, Natrum Mur, Platina, Sepia, Staphysagria etc. (13) |