Is depression a joke? Professor Sivolap - about misconceptions about depression

Is it true that depression goes away over time if you have the right mindset? How does alcohol affect depression? Is it possible to get hooked on antidepressants? Doctor of Medical Sciences Yuri Sivolap answered these and other questions about depression in an interview with Anews.

The coronavirus pandemic, the collapse of the ruble overnight, the collapse of economic growth, the risk of job loss - these reasons can despondency and lead even the most balanced person to depression. Doctor of Medical Sciences Yuri Sivolap spoke in an interview with Anews about what myths accompany depression and methods of its treatment.

Yuri Sivolap – Doctor of Medical Sciences, Professor of the Department of Psychiatry and Narcology of the First Moscow State Medical University named after. THEM. Sechenov, author of over 100 scientific articles, monographs and clinical guidelines.

Depression is the most common mental disorder currently existing; every seventh person in the world can suffer from it during their lifetime. But even among doctors there is often an idea that mental disorders, unlike “real” diseases, can be corrected by one’s own will, and the patient just needs to pull himself together. And if we talk about mental disorders, even seemingly mild ones, like some forms of phobias and depression, then we have to admit that what is nested in the head is difficult to control, if at all possible. But there are a lot of myths among doctors and patients about how a person develops depression and how to treat it.

Let's figure it out.

Myth No. 1: “Depression is not a disease, but a stupidity and a whim”

Depression is an idiot and a whim in exactly the same way as hypertension. Like other serious illnesses, depression is a physical illness, it has a biological basis, it has medical causes, mechanisms of development and a risk of premature death.

Nikolai Neznanov, chairman of the board of the Russian Society of Psychiatrists and director of the Bekhterev National Medical Research Center for Psychiatry and Neurology in St. Petersburg, said: “I don’t see a fundamental difference between depression and chest pain.” That is, both angina and depression need to be treated with medications. Acute angina should be treated with nitroglycerin, depression with antidepressants.

If a person with depression is not treated, he will join the ranks of suicides. The suicide rate in severe depression can be as high as 13%, which is approximately 20 times higher than suicide rates in the general population. The average life expectancy of people with depression is shorter than that of healthy individuals due to suicide, alcohol abuse, accidents and related illnesses.

The first symptoms and signs of depression:

Depressed mood all the time almost every day
Decreased interest or pleasure in almost all activities that were previously enjoyable
Significant weight loss without changing diet, or weight gain, or decreased/increased appetite
Insomnia or hypersomnia
Psychomotor agitation or retardation
Fatigue or loss of energy
Feelings of worthlessness or excessive, inappropriate guilt. This feeling may be delusional, i.e. not connected in any way with reality.
Decreased ability to think, concentrate, or persistent indecisiveness
Recurrent thoughts of death (not just fear of death), suicidal ideation without a specific plan, first suicide attempt, or specific plan to commit suicide.

These symptoms may cause the first clinically significant disorders and signs of impairment in social, professional or other important areas of life. It is important to ensure that these initial episodes are not side effects of any substance or symptoms of other (physiological) medical conditions.

Important If the above symptoms last more than 2 weeks, then this can be diagnosed as an illness (depression) and the person needs the help of specialists.

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Myth 2: “Depression will go away on its own, there is no need to treat it”

To the question “Tell me, will my torment ever end?” a doctor who does not have a psychiatric education may answer: “They will definitely end!” After all, you are not immortal...” But in fact, from the point of view of classical psychiatry, depression is the affective phase of the disease, an attack that can last from several months to several years, during which time the patient’s quality of life will be significantly reduced.

If depression is not treated, the patient may experience irreversible structural changes in the brain, for example, hippocampal atrophy, and the risk of developing Alzheimer's disease greatly increases.

Therefore, depression must be treated as quickly as possible to reduce the possibility of dementia. Another consequence of advanced depression is decreased ability to work and an increased likelihood of premature death.

Myth #3: “Depression is just a bad mood. You just need to cheer a person up"

A persistent decrease in mood during depression is not a bad mood that a healthy person can have. Trying to cheer up a person with depression is the same fruitful idea as eliminating a person’s hypertensive crisis by showing him a comedy movie, or trying to relieve the pain of a patient who has broken his leg by telling him a joke. Any external stimuli and communication can be painful during depression: people with this disease often seek solitude. Their emotional resonance to significant events, both joyful and sad, is significantly reduced and so-called painful insensibility occurs.

Myth #4: “Alcohol relieves depression”

Alcohol while intoxicated can ease your mental state. But then it only gets worse. For many, depression from alcohol only intensifies. Alcohol itself causes it: in the pair “alcoholism – depression”, each of the diseases doubles the risk of developing the other, and the ability of the first disease to a greater extent to cause the appearance of the second has been proven than vice versa.

Alcohol impairs cognitive functions that are typically impaired in depression, such as memory and attention. This is perhaps the most brutal psychoactive substance known, and it affects the brain much worse than many illegal drugs.

How to diagnose somatized (somatic) depression

It is difficult to correctly diagnose this condition, since a person is tormented by symptoms from the body, not the psyche. People try not to talk about their bad mood or anxiety because they are afraid of contacting a psychotherapist or psychiatrist. Because of this, questions about mental state cause irritation and negative reactions.

To make a correct diagnosis, the following points are taken into account:

a complete thorough examination did not reveal any serious abnormalities in the functioning of the internal organs;
daily fluctuations in somatic disorders in depression are one of the important markers; Seasonal exacerbations of pain are often characteristic; the severity of symptoms may decrease in the evening; analgesics do not provide relief;
repeated visits to different doctors and undergoing numerous tests, despite previous negative (not confirming the presence of a serious somatic disease) results.

Due to constant pain of unknown origin, such patients have a high risk of developing drug, alcohol or drug addiction. For the occurrence of somatic symptoms of depression, a lack of significant support in life from loved ones is quite characteristic. In this way, people try to get the care and attention they need.

Myth No. 5: “People shouldn’t be put on antidepressants, it’s dangerous”

This phrase can often be heard from doctors of other specialties. Not psychiatrists, but, for example, therapists. So, in case of serious depression, the patient must be prescribed antidepressants, otherwise his condition may worsen greatly. Moreover, the course of treatment will take at least six months for the disease to go away. Modern antidepressants, no matter how many people, even doctors, fear and demonize them, are no more dangerous than the medications that therapists use in their practice.

Myth #6: “Are you depressed? Go to a hospice and see real suffering."

This myth is a typical example of a moralistic judgment. The suffering of a person with depression can be unbearable. Many patients tell their doctors that they are willing to endure the physical pain rather than the excruciating numbness they experience.

Why are moralistic judgments and advice dangerous for depression? A person already blames himself for everything, exposes himself to condemnation even without demands from the outside.

And then friends and relatives come with the words: “You have a daughter, think about her!” or cheerful calls: “Come on, are you small?”, which do not help, but often contribute to suicide due to feelings of guilt.

Vladimir Lvovich Levi, who once worked with us at the First Medical Institute in the Korsakov Clinic, owns the phrase: “Depression is a state in which it is easier to unload a carload of bricks than to pick up a telephone.” It's hard to answer the phone. Any communication is painful.

Myth #7: “Are you depressed? Go work!”

With exactly the same success, one can advise a person with diabetes to go unload a wagon of bricks.

Is so-called “occupational therapy” necessary at all? Yes, it is needed by workers in hospitals, boarding schools and rehabilitation centers who force people with depression or alcoholism to dig up beds, clean wards or help prepare food.

At the same time, patients often also pay money for this, and considerable money at that. This takes the workload off the staff, which I think is well settled.

In my opinion, occupational therapy cannot help people suffering from depression or alcoholism. Among my patients with depression or alcohol addiction, many are real workaholics.

There is also such a problem as doctors being predisposed to depression. It is explained by the fact that people in this profession work a lot and hard, they have a high level of responsibility and stress, and they experience a lack of approval from others. Any mistake will result in a scolding from the chief physician, and in a difficult situation he may not support his subordinate. And if a doctor works at one and a half or two rates, which often happens, he cannot be called a slacker. He doesn't need occupational therapy; he works too much without it. One of the recent American scientific papers reports the results of a survey of young medical trainees for the period from 1963 to 2015. And every third young doctor who is still learning his profession shows signs of depression.

Symptoms of depression and somatic sensations

Emotional disorders such as anxiety, apathy and despondency are among the main manifestations. But in latent depression they are ideally disguised as other pathological manifestations. A person is sure that his low mood is associated with an unknown illness, anxiety about health is logically understandable, and it is a somatic illness that causes weakness and fatigue, apathy, and not a mental disorder or depression.

Somatic symptoms of depression include:

Chronic pain is a common companion to this condition. Its localization changes quite often (but can also have a long-term constant localization); sometimes pain occurs simultaneously in different parts of the body. The intensity of pain can vary in severity. People describe their health as “heavy head”, “dull pain”, “pulling the back”, “pressure in the chest”, “burning in the hands”, etc., as a condition accompanied by tedious, exhausting pain.
Loss of appetite - accompanied by severe loss or gain of body weight. It can be expressed in both anorexic behavior and overeating. A person may not feel hunger at all, or, on the contrary, experience it constantly. Or convey it and not notice it - “I eat out of habit.”
Sleep disorders are an important symptom that signals exhaustion of the nervous system. Restless and/or interrupted sleep, difficulty falling asleep, waking up early with anxiety, nightmares, and feeling groggy in the morning are all somatic manifestations of depression.
Asthenic syndrome - this symptom is associated with increased fatigue, constant fatigue, and decreased performance. It is difficult for a person to concentrate on everyday activities. With a small load, severe fatigue occurs that does not go away after rest.

Doctors also include problems in the sexual sphere as somatic signs of depression. This is a decrease or complete absence of sexual desire, erectile dysfunction in men. Women often complain of menstrual irregularities or increased premenstrual syndrome.

There are no mood swings observed. People usually describe their mood as “usual”, “not important”, “nothing”, “what kind of mood can you be in when you’re sick?” There is irritability, dissatisfaction, grumpiness, confusion. Physical symptoms are more eloquent and varied: there may be tachycardia, dizziness, shortness of breath, numbness, tremors in the limbs.

Myth No. 8: “Depression was invented by Big Pharma, which promotes antidepressants”

This is as brilliant an idea as the idea that darkness was invented by light bulb manufacturers, hunger by bakery owners, and distance between continents by airlines and satellite operators. Of course, if humanity has any need, there will always be businessmen who make money from it.

Depression has been known since ancient times, it was described by Hippocrates, calling it melancholy, and it appeared long before the advent of the pharmaceutical business. In the absence of antidepressants, there was practically nothing to treat it, and their use alleviates the suffering of many people, often allowing them to get rid of it completely. This applies to at least 70% of patients. Perhaps the use of antidepressants is one of the reasons that depression is now noticeably easier and milder than several decades ago. Many cases can now be treated on an outpatient basis without hospitalization.

Pathomorphosis - a shift in the course of many diseases to a milder form - occurred not only in depression, but also with many other mental illnesses, for example, schizophrenia. The same thing happened in other medical areas, for example, in cardiovascular diseases and joint diseases such as rheumatism. Of course, pharmaceutical companies make a profit from the production of antidepressants, like other vital drugs, this is their business, this is how the modern economy works.

Genes make mistakes

Image from asuh.org
Depression cannot be said to be hereditary. But what can be inherited are combinations of genetic variants that predispose a person to depression.

Genes encode the production of proteins necessary for all biological processes in the body, including the brain. Throughout human life, different genes are “turned on” and “turned off” at a certain moment, because each protein has its own time.

Failures in these processes can lead to emotional instability, and then an external factor, even not very significant (a missed deadline for work or the flu), can throw the system out of balance and trigger depression.

Myth No. 9: “Depression is the cause of cancer”

This statement is the only one with which I don’t want to argue. When depressed or when a person is in a state of severe, irresistible stress, his immunity, including anti-cancer immunity, may decrease. It is believed that 14 cancer cells are formed in the body of each of us every day. But they are safely killed by T-lymphocytes, killer cells. With depression or severe stress, their activity decreases, which, in turn, can contribute to the appearance of a malignant tumor.

Depression and serious physical illness are also linked. Its symptoms are observed on average in every third surviving patient with cerebral stroke, other cardiovascular and other serious diseases. When someone is depressed, they literally give up. He lacks the motivation to go to a psychotherapist and take the necessary medications. If we treat a patient—there is a lot of research on this—the course of his other diseases improves. For example, if he has coronary heart disease, taking antidepressants reduces the risk of myocardial infarction. If it does happen, antidepressants increase survival and reduce the number of deaths.

Depression increases the risk of uncontrolled hypertension. New evidence

Depression is a universal illness

Depression is a relatively common disease that affects all segments of the population, regardless of social status. This is a mental disorder characterized by decreased mood and loss of the ability to experience joy, impaired thinking, and motor retardation. Many different methods have been developed to treat depression, including psychotherapy and pharmacotherapy. The latest guidelines for the treatment of this disease recommend the use of antidepressants from the group of serotonin reuptake inhibitors or short psychotherapy focused on the patient's most pressing problems as first-line treatments. In addition to the drugs mentioned, tricyclic antidepressants, serotonin and epinephrine uptake inhibitors, and monoamine oxidase inhibitors can be used in the treatment of patients with depression. However, their use is limited by the combination of side effects and concomitant pathology of organs and systems. Many psychotherapeutic methods have also been developed, including cognitive, interpersonal, behavioral therapy, and self-control therapy. There is information about the use of herbal preparations, but the effect seems unproven. Currently, given the concern of patients with the variety of medications they receive and the availability of information about the side effects of therapy, including in the public domain, the impact of the ability of patients with depression to discuss with their doctor and participate in the selection of the therapy they receive on improving their condition is being discussed.

Depression and cardiovascular pathology

Depression is often associated with a negative impact not only on the mood and well-being of the patient, but also damage to his organs and systems, which has been confirmed by many studies. Arterial hypertension occupies an important place among depression-mediated pathologies, which leads to an increased risk of developing cardiovascular pathology in patients. Recent data regarding the relationship between depression and hypertension indicate the involvement of amines in the body in both processes; there is evidence of a decrease in the production or relative lack of monoamines (serotonin, norepinephrine and dopamine) in the central nervous system. This is supported by the effect of antidepressants on monoamine-related neurotransmitters. In both patients with depression and hypertension, there is an increase in the tone of the sympathetic nervous system, an increase in the secretion of adrenocorticotropic hormones and cortisol, which may indicate a relationship between these two pathologies.

Dopamine and other neurotransmitters released by special cells have an antihypertensive effect. A lack of dopamine in certain areas of the brain, on the contrary, leads to increased blood pressure and may be a trigger for the development of depression. The feedback is also discussed, when in patients with cardiovascular pathology, due to ischemic changes in the brain, the predisposition to the development of depressive states may increase.

Despite the above, and also taking into account the high prevalence of depression among patients with chronic diseases, this disease is rarely recognized in a timely manner by primary care physicians, and therefore, patients with depression and hypertension rarely receive adequate treatment. In the UK, the United States Preventive Services Task Force recommends “screening adults for depression to improve the accuracy of diagnosis, appropriate treatment and management.”

In order to determine the effect of depression on blood pressure levels in patients with hypertension and confirm the justification of such screening, scientists from Mexico City conducted a study.

Methods

The study included 40 patients who were diagnosed with hypertension, for which they received antihypertensive therapy for at least 6 months. Exclusion criteria were the presence of secondary hypertension, hypothyroidism, mental illness in the patient, taking centrally acting antihypertensive drugs, a history of alcohol or psychotropic substance abuse, or taking antidepressants for any reason. The subjects were trained to measure blood pressure using an automatic blood pressure monitor (OMRON HEM713C, OMRON Healthcare Inc, USA) for a week. Using a cuff of appropriate diameter, they measured blood pressure three times a day: in the morning after waking up, before lunch and before bed. Each time, the pressure was determined after a 5-minute stay in a sitting position, three times in a row with an interval of 3 minutes. To assess adherence to antihypertensive therapy, both study participants themselves and their relatives were interviewed. All patients were tested for depression using the Self-Esteem Scale developed by Zung et al. The maximum score is 80 points; the diagnosis of depression is established when the patient scores more than 50 points. After receiving the results, a statistical analysis was performed with an assessment of the Spearman correlation coefficient.

results

According to testing, 23 patients (57.5%) were diagnosed with depression. In 21 of them, blood pressure was not controlled by antihypertensive therapy, and in only 1 person hypertension was controlled. Among the remaining 17 people without depression, the results were the opposite. In only 1 patient, blood pressure was difficult to control; in the remaining 16, classical antihypertensive therapy had a positive effect. The mean blood pressure in patients with hypertension and depression was 158/89 mmHg, while in patients without depression it was 125/77 mmHg.

Conclusion

The results obtained once again confirm the presence of a close connection between depression and difficult-to-control hypertension. The authors of the study note that, in view of this information, screening for depression is indicated for patients with hypertension, especially since its implementation using testing on the Self-Monitoring Depression Scale does not require financial investments. It may also be worth considering antidepressants as one of the most important drugs in the treatment of uncontrolled hypertension.

Source:

Alberto Francisco Rubio-Guerra et al. Depression increases the risk for uncontrolled hypertension. Exp Clin Cardiol. 2013 Winter; 18(1): 10–12.
Meng L, Chen D, Yang Y. Review Depression increases the risk of hypertension incidence: a meta-analysis of prospective cohort studies. J Hypertens. May 2012; 30(5):842-51.