Questions about depression - interview by Simona Tache

How common is depression these days?

Depression is one of the most common disorders in the population, and the risk for any of us to develop a lifelong depressive disorder is 15%. According to the World Health Organization (WHO), depressive disorder is currently the fourth leading cause of disability, and by 2020 it is estimated to reach second place after cardiovascular disease.

Depression is 2 to 3 times more common in women than men, the average age is 40 years for both sexes, 50% of cases starting before age 40, and 10% after age 60. According to the WHO, 10-15% of mothers are depressed after birth, thus affecting their ability to care for the child, with consequences for the mother-baby relationship and the psycho-affective and cognitive development of the baby.

When do we have to realize that we have a problem that we can't solve on our own? When do we have to decide that we need psychotherapy? But the one in which we must become aware that psychotherapy is not enough for us and that it must be supported with medication?

We realize that we need help when we feel that things are getting out of hand, when the intensity of suffering is too great, or when we want to change things, ways of functioning. If we are talking about a mild depression, psychotherapy may be sufficient (but not necessarily, and here good communication between doctor and patient is important), if the depression is serious then pharmacotherapy with or without psychotherapy is recommended. This decision takes into account a multitude of factors: the intensity of suffering, the degree of dysfunction caused by depression, how stressful the patient's professional and family living environment, etc., and the psychiatrist and patient will decide together on the therapeutic approach. When there is a psychiatrist and a psychotherapist it is important to have good communication between them.

Contemporary psychiatric thinking agrees with the combined use of medication and psychotherapy, due to the greater benefits of studies. Contrary to popular perception, medication does not erase awareness of problems but improves cognitive functions, lowers anxiety, allowing patients to better understand and express their emotions, feelings, thus facilitating a process of introspection in psychotherapy. Medications can be adjuvants of psychotherapy, they alleviate most symptoms, but without being able to correct the functioning deficits in the patient's life; in turn, psychotherapy can have a favorable effect on patient compliance, disease progression, and patient quality of life. Therefore, an integrative approach is currently preferred.

How long does an average treatment for depression last?

The treatment of depression lasts on average between 6-9 months, depending on the severity of the depression and the number of previous depressive episodes. If the evolution is favorable, the antidepressant treatment gradually decreases after 6-9 months, under medical supervision. If there have been several depressive episodes in the past, then maintenance treatment lasting several years or sometimes a lifetime will be required.

It often happens that the patient stops the antidepressant treatment earlier and without the consent of the psychiatrist, a situation in which the risk of relapse increases.

Patients should be aware that the effectiveness of an antidepressant treatment cannot be assessed earlier than 4 weeks, as there is a latency period in the onset of beneficial effects present in all antidepressants.

Where can an untreated depression lead?

Untreated depression has a major impact on the quality of life of the patient and his entourage. Symptoms of depression: decreased interest and pleasure, fatigue, decreased ability to concentrate, irascibility, etc. - have a negative impact on the social functioning of the patient, both in the family and at work, thus affecting their ability to work, to love, to spend time with loved ones, to feel satisfaction, satisfaction or pleasure in his life.

These things accentuate the patient's feelings of incurability, uselessness, undesirability, thus strengthening a vicious circle.

Depressed people have worse mental and physical condition, have worse social relationships to nonexistent, tend to isolate themselves socially, have a high risk of risky behaviors (alcohol and drug use) which leads to financial problems, problems of the couple, and last but not least, at the risk of a suicide attempt.

Often, untreated depression has a great somatic resonance - what we call masked depression, in which depressive symptoms are camouflaged by somatic symptoms, the most common being gastrointestinal disorders with colic, loss of appetite, weight loss, headache, low back pain. , palpitations, pain in the genitourinary sphere, chronic pain: stomach, teeth, etc. This patient is a heavy consumer of medical services, urgently reaching various specialties, and only eventually, late to the psychiatrist.

What happens to treated depression? Disappear forever? Can they come back?

The evolution of depression is usually recurrent, in 25% of cases even chronic. Statistics say that the probability of recurrence is 50% after a single depressive episode, between 50-90% after two depressive episodes and over 90% after three or more episodes.

The factors that favor relapse are the increased number of previous episodes, premature / too fast interruption of antidepressant treatment, psychotraumatic environment, other somatic or mental illnesses, addictive behaviors, etc.

Major depressive episodes can be resolved completely (in almost 2/3 of cases), or only partially (1/3 of cases). Episodes of major depressive disorder often follow a major stressor, such as illness or death of a loved one or divorce. Psychosocial stressors may play an important role in precipitating the first or second depressive episode, but their role diminishes in subsequent episodes. Of course, other somatic diseases or addiction to a substance (most commonly alcohol) can contribute to the onset and exacerbation of major depressive disorder.

Is medication associated with depression addictive?

Depression is treated with antidepressants. Antidepressant treatment is NOT addictive. If the patient has significant anxiety, anxiolytic treatment may be added to the andipressive treatment for a limited period of time. This treatment with anxiolytics can lead to addiction if it is prolonged for more than 2 months. The tolerance effect is manifested by the fact that the medicine no longer works at the same dose and it is necessary to increase the doses to obtain the same effect. It should also be noted that the abrupt discontinuation of the anxiolytic occurs the effect of withdrawal, manifested by psychomotor anxiety, tremor, discomfort.

Returning to your question, antidepressant treatment is NOT addictive, but it is a treatment that requires monthly supervision and monitoring (at the beginning even more often) of the psychiatrist.

What do we do when we have someone very close to us in a very serious depression, but who vehemently denies it? How can we persuade him to accept the doctor's help?

This is always a delicate situation, which requires a lot of tact, diplomacy and a lot of patience. I recommend an empathetic and genuinely concerned attitude towards the person with depression, accompanied by clear explanations, that depression is a treatable disease. Often, due to social stigma, people do not know they are suffering from an illness, and may feel relieved to learn that their suffering can be treated by a doctor.

Support in seeking medical help can be of real use; for example, making an appointment with a doctor, accompanying the patient to present the symptoms to the doctor (often the patient tends to minimize his suffering, and the information provided by the family is extremely valuable), etc.

Is it mandatory for depression to have a concrete, palpable cause, such as "I'm depressed because my wife left me"? Or can it occur even though, in theory, we have every reason to be well? When Robin Williams committed suicide due to depression, many people did not understand why a man who "had everything" chose to die.

Depression does not have a single cause, but is the result of a multifactorial vulnerability to depression: genetic (genetic risk is about 10-13% for first-degree relatives), biochemical (imbalances in neurotransmitter levels: serotonin, dopamine, norepinephrine, etc. in brain), biological (there are changes in brain structures involved in affective-emotional circuits, changes that result in disruption of information transmission between brain structures), stress, etc.

The most stressful life events associated with depression are: the loss of a parent in childhood or parental abandonment, emotional trauma, abuse, divorce or loss of a partner, job loss. The onset of the first depressive episode is often precipitated by a psychotraumatic factor.

There are studies that have shown that early experiences of abuse, abandonment, neglect or separation can create a neurobiological vulnerability that predisposes the person to respond in adulthood to a stressor with the development of a depressive episode. Here, too, there are differences: women who were separated from their mothers as children have an increased risk of depression, a high risk of depression after the birth of their first child, and men appear to be more vulnerable to depression after a divorce / separation or work-related problems.

Where does this Bau-Bau image of the psychiatrist who has a great pleasure in turning us into vegetables come from? How do we get rid of it?

The anti-psychiatric perception is old, with it being faced by psychiatrists in developed European countries, or the USA, and is unfortunately difficult to combat. From my point of view, not going to the psychiatrist in case of mental illness is as serious as staying home in case of myocardial infarction or acute abdomen. Like somatic suffering, sometimes even more than this, mental suffering is painful, disabling and can endanger the patient's life. It is a prejudice, which - like any prejudice - is based on ignorance or fear of the unknown. Most of the time, after arriving at the office, patients understand how distorted their perception of the meeting with the psychiatrist was.

There is an ancestral fear, even a horror of mental illness, from the time when the mentally ill were considered to be possessed by demons, or later when mental illness was seen as a defect in character. Of course, the cinematography didn't help psychiatry much either, images like the ones from "Flying over a cuckoo's nest" remaining alive in the collective mind. In addition, I believe that mental illness is generally perceived as a failure to be hidden.

Even among physicians and medical students, this image is maintained (the medical professional body has a much higher risk of depression than their non-medical colleagues; it appears that approximately 400 physicians die each year in the United States by suicide, and the incidence of depression among medical students is somewhere between 15-30%), psychiatry remains the ashtray of medical specialties. Things have started to change in our country in recent years, unfortunately not due to a change in perception, but due to the fact that there is an acute need for psychiatrists in the West, and therefore it is very easy to leave the country with this specialty, as a resident or as a young specialist.

But beyond these considerations, the human brain is a complex organ, which hardly reveals its secrets, mysteries. In addition, in psychiatry, in order for the patient's suffering to be understood, a certain degree of openness, confession, and personal revelation on his part is required. Therefore, the meeting with the psychiatrist is not an ordinary meeting, but a special meeting, attended by the entire internal theater of the patient, his entire family novel, sometimes with conflicts or traumas transmitted transgenerationally. At the meeting with the psychiatrist, the patient brings himself, his family and a whole range of feelings: fear, anxiety, guilt, phobia, aggression, shame, love, or broken connection between affection and body, as in psychosomatic disorders. Therefore, meeting with a psychiatrist is not an easy meeting.

How can we get rid of this evil image of psychiatry?

It is a difficult question that other countries are facing. Personally, I believe that there is a need for a greater openness of psychiatrists, a greater willingness to communicate with the patient, with his family, and an involvement - perhaps in prevention activities at the level of community psychiatry. Also a better communication / information of family doctors and other specialists, so that they can send patients to psychiatry without fear of stigmatizing them. And last but not least - maybe another approach in the media, which often conveys a distorted picture of psychiatry and the psychiatrist, and which, perhaps, could better educate / inform the general public.

Most of the time, people do not know that the psychiatrist is a doctor, that he does a 5-year (residency) training in psychiatry (just like a cardiologist or a surgeon does) and that his job is to deal with mental illness.

What other sister diseases of depression ruin the life of modern man?

Anxiety disorders are by far the most common psychiatric disorder, with anxiety symptoms occurring in many somatic diseases. Socio-economic conditions, fast pace of life, pressure from employers, new technologies are factors that favor these disorders.

Dr. Mihaela Dumitru, psychiatrist, interview www.simonatache.roMay 2015