WHAT IS MEANT BY THE TERM "DEPRESSION?"

The medical condition referred to as Clinical depression is not to be confused with the transitory everyday experience of a mild mood swing that everyone experiences during difficulties. Just as we feel happy or fearful or jealous or angry, we are all "depressed" from time to time. On the other hand, clinical depressive illness is a very disabling, unpleasant and prolonged state. By the way, it is the most common psychiatric condition seen in the general populaton, as well as in the medical practice. Clinical dperession may bring on a variety of physical and psychological symptoms: sadness and gloom, spells of crying, insomnia, or restless sleep, loss of appetite or eating too much, uneasiness or anxiety, irritabiliyt, feelings of guilt or remorse, lowered self-esteem, inability to concentrate, diminished memory and recall, indecisiveness, lack of interest in things formerly enjoyed, fatigue, and a variety of physician symptoms such as headaches, palpitations, diminished sexual interest and/or performance, other body aches and pains, indigestion, constipation or diarrhea, etc.

Not all people who suffer from clinical depression have all of the above symptoms. Patients are considered to be clinically depressed when they have a depressed mood, disturbances in sleep and appetite and at least one or two of the symptoms mentioned above which last for several weeks and are severe enough to disrupt daily life.

While there are many symptoms associated with clinical depression, there are seven which indicate the depth and degree of depression. These are: sense of failure, loss of social interest, sense of punishment, suicidal thoughts, dissatisfaction, indecision, and crying.

Two of the most common psychological signs of Clinical depression are hopelessness and helplessness. People who feel hopeless believe that their distressing symptoms may never get better, whereas people who feel helpless think they are beyond help, that no one cares enough to help them or could succeed in helping, even if they tried.

HOW COMMON IS DEPRESSION IN THOSE WITH LUPUS?

Some psychiatric and medical studies state that 15% of those with a chronic illness suffer from clinical depression. Others place this figure as high as 60%. Although Clinical depression is certainly more common in people with chronic medical illness, than in the general population, not every patient with a chronic illness suffers from clinical depression. Episodes of clinical depression usually last for only a few months in patients with a chronic illness.

Depressive illness often goes unrecognzied in those who have other medical illnesses because it presents symptoms so similar to those of the underlying medical condition. In systemic lupus, symptoms of depressive illness such as lethargy, loss of energy and interest, insomnia, and intensification, dimished sexual interest and/or performance, etc., can quite naturally be attributed to the lupus condition.

Even in those individuals without chronic medical conditions, most cases of depressive illness go unrecognized and untreated until the later stages of the illness when the severity of the depression becomes unbearable to the patient, and/or until the family or physician can no longer ignore it. In fact, several studies indicate that between 30-50% of cases of major depressive illness go undiagnosed in medical settings. Perhaps more disturbing is that many studies indicate that major depressive disorders in the mentally ill are undertreated and/or inadequately treated, even when recognized.

Many patients refuse to acknowledge that they are in a depressive state and will actually deny that they are feeling unhappy, demoralized or depressed. This group of individuals often experience what physicians called "masked" depression. These patients resist the notion of emotional distress, substituting in its place various physicial complaints.

Physicians who are familiar with their patients' usual mood and personality, as well as their lifestyle and situation, are more likely to recognize changes associated with depressive illness. Similarly, patients are more apt to open up about their feeligs when they are encouraged to do so by a physician they trust and with whom they are familiar.

Unfortunately, there is all too common a distored notion that those with a chronic illness have "reason to feel depressed becasue they are sick." This belief interferes with earlier recognition, earlier treatment, and earlier relief of suffering from Clinical depression. This belief also ignores the fact that clinical depression in the physicaly ill generally respond well to standard psychiatric treatments and that patients treated only for their physicial illness will suffer needlessly the effects of clinical depression.

WHAT IS THE CAUSE OF DEPRESSION IN LUPUS?

There is no one cause of clinical depression in lupus; rather, there are various and different factors contributing to depression in chronic illness such as lupus. The most common cause is the emotional drain caused by the continuous series of stresses and strains associated with coping with the chronic illness and medical condition. Other causes may be the many sacrifices and losses required by the continuous life adjustments that a patient with a chronic illness must make.

Various medications used to treat lupus such as steroids, may induce depression. Lupus involvement of certain organs such as the brain, heart and kidneys can also lead to depression. There are also many unrecognized or unknown factors which may cause depressive illness. Of course, there are lupus patients who would develop clinical depression whether or not they had lupus.

WHAT IS THE TREATMENT AND PROGNOSIS OF DEPRESSION IN LUPUS?

Effective treatment requires early diagnosis and early intervention. Fortunately, most episodes of depressive illness in people with lupus are short-livd and subside on their own within a few months. Just as some lupus pateints can tolerate a lot of pain, some seem to be able to accept and tolerate major symptoms of depressive illness without complaint. Depression is very stressful and anxiety producing, which may exacerbate the lupus. Depressive reactions should be treated with the same aggressiveness and persistence that one would use to treat a lupus flare, or any other medical complaint. Naturally, any underlying medical condition that could contribute to the depression must be identified and controlled.

Today, effective treatment is available for depressive illness and usually consists of psychotropic medication, psychotherapy and, most often, a combination of both. Anti-depressant medications are the drugs that ar most often used; the four categories are: tricyclics, newer generation non tricyclic anti-depressants, MAO inhibitors and lithium. The effectiveness of these medications may be increased by using them in combination or by the addition of other medications.

Adequate and aggressive treatment involves the cooperation of the patient, and the support, education, and involvement of the patient's family and close friends. Such treatment may involve blood tests to determine the appropriate dosages of medication, open communication between the patient and treatment team, and a large ration of optimistic support in the form of encouragment, patience, availability, and perseverance from the patient, his/her physician, and his/her family and close friends.

Naturally, any undrelying medical factors that contribute to the depressive state must be identified and addressed. Anti-depressant medications are associated with various side effecs and may intensify various symptoms associated with lupus. When anti-depressant medication are effective, there is a welcome improvement in the patient's sense of well-being and overall attitude and adjustment.

Recovery from depression is usually a gradual process. Dramatic improvements do not usually occur in a few days; however, one begins to see some progress after a few weeks. Even when signs of clinical depression seen to clear quicly, it isn't unusual for an inidivudal to relapse when the medication is stopped. For this reason, medication should be continued for approximately six months or longer and the dosage should be tapered slowly over a 3-4 week period when treatment is discontinued.

In patients with depressive illness, there is often a general slowing and clouding of mental functions. These troublesome and not infrequent disruptions in mental functioning tend to go underreported to their physicians and are rarely confirmed to be due to any specific structural change. Fortunately, these transient alterations in mental functioning improve as the depressive condition improves.

Psychotherapy can be very helpful in assisting people with clinical depression to work through and understand their feelings, their illness and their relationships, and to cope more effectively with stress and their life situation. The benefits to the patient are best served when the primary care physician maintains a close relationship with their psychiatrist or psychologist. Such a working relationship maximizes the quality of patient care and provides the most powerful approach to the management of depression.

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