Clinical depression is not just about being down or feeling blue. It’s a medical condition that needs treatment.
CLINICAL depression, commonly known as depression (also termed major depressive disorder, or MDD, by doctors) is a significant mental health problem. Some may mistake depression with feeling sad or “down”, but it is considered a disorder when it impacts a person’s day-to-day life, interfering with the ability to work, eat, sleep, or have fun.
Approximately 5% to 10% of people in a community at any given time are in need of help for depression, with the average onset occurring between 20 and 40 years and affecting individuals across all ethnicities and nationalities, with a slightly higher incidence among women.
At its worst, depression can lead to suicide, which is associated with approximately 850,000 deaths each year.
Depression in Malaysia
Left untreated, depression can last for six months or more. While a majority of patients improve significantly with treatment, clinical depression often has multiple episodes of relapse.
A study conducted among adults in primary care settings reported a prevalence of 5.6%, while other data suggests that 80% of individuals who experience a major depressive episode will have at least one more episode during their lifetime. Furthermore, approximately 12% will experience chronic (ongoing) depression.
Common signs and symptoms
While all people may experience the following at some point in their lives, symptoms that last more than two weeks are indicative of a depressive episode that may require treatment.
Typical symptoms include a depressed mood, loss of interest and enjoyment, and reduced energy. Other common symptoms include:
? Reduced concentration and attention
? Reduced self-esteem and self confidence
? Ideas of guilt and unworthiness
? Bleak and pessimistic views of the future
? Ideas or acts of self-harm or suicide
? Disturbed sleep
? Diminished appetite
It is crucial that depression is diagnosed and treated early with the appropriate medication, as researchers have found that the likelihood for depressive episodes to recur becomes more likely with each episode – after the first episode, the chances of it recurring is less than 50%, but after the second episode the likelihood increases to 70%, and after the third episode, the likelihood is more than 90%.
Treatment can be provided in the form of psychological and pharmacological intervention.
For mild clinical depression, supportive and problem-solving therapy, counselling and cognitive behavioural therapy can help patients cope better, and may be administered together with pharmacological treatment.
Moderate to severe clinical depression usually requires medication in combination with psychological intervention. A class of drugs known as selective serotonin reuptake inhibitors (SSRIs) is considered as first-line medication, as they are better tolerated when compared to other types of treatments.
The following are some of the types of drugs prescribed for depression:
? Tricyclics/tetracyclics and monoamine oxidase inhibitors (MAOIs) are older treatments which are effective but associated with side effects. They are also known to interact with other medicines and foods, but remain an important form of treatment for those who are not responding well to newer treatments.
? Selective serotonin reuptake inhibitors (SSRIs) work by blocking a receptor in the brain that absorbs the chemical serotonin, thereby influencing a person’s mood, outlook, and behavior.
? Serotonin and noradrenaline reuptake inhibitors (SNRIs) affect levels of both serotonin and another brain chemical, norepinephrine, to treat symptoms and help prevent relapse. SNRIs may be used as an alternative treatment for depressed patients who do not tolerate or respond adequately to treatment with a conventional antidepressant (SSRIs).
One of the newer SNRIs have been studied and found to both efficacious and well-tolerated. Studies have found that patients treated with this new SNRI had low discontinuation rates due to adverse events, indicating good tolerability to the treatment.
Furthermore, there was no need to titrate (increase) the dose to an effective level in order to prevent early side effects – patients were able to start treatment at the recommended therapeutic dose without sacrificing tolerability. Researchers also found that it is less likely to interact with certain medications, a beneficial feature for patients being treated for other conditions.
Treatment insights in Malaysia
A Pfizer survey, which involved interviews conducted with 46 general physicians and psychiatrists from April to June 2010, noted the following trends and perceptions among healthcare professionals about depression issues:
Prevalence: The majority of doctors noted that the number of people being treated for depression had increased over the years, and that this trend will continue.
More than 90% of those interviewed also believe that depression is under-diagnosed. However this may not necessarily indicate that more people are becoming depressed; instead it could merely indicate that many who were previously undiagnosed are becoming more aware and seeking treatment.
Treatment-seeking behaviour: General physicians are the first line of contact for those seeking help with symptoms of depression while those with severe symptoms are usually referred to psychiatrists. Approximately 62% of those seeing psychiatrists are referred from general physicians.
In this way, both general physicians and psychiatrists play an important role in evaluating, diagnosing and treating depression.
Challenges to diagnosis and treatment: Several social and personal barriers delay diagnosis, which include social stigma, lack of family support, low patient awareness about the condition, and denial from patients who are unable to accept that they require treatment.
Among those already diagnosed, cost of medication, poor compliance with treatment, and side effects are common challenges.
Important factors in treatment: Efficacy, safety profile, and affordability are the three most important factors considered by doctors in prescribing treatment, with affordability often becoming the main deciding factor due to the need for long-term treatment.
Due to the wide range of patient profiles, there is no gold standard treatment for depression – both general physicians and psychiatrists use a range of treatments to help patients control and alleviate the symptoms of depression.
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