DEPRESSION : LET’S TALK

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  • Dr. Aung Soe @ Aung Kyaw Moe
    Retired State Medical Superintendent

The above mentioned slogan is meant for World Health Day 2017 which falls on April 7. As the depression cases are on rise globally as well as in Myanmar, together with increased incidence of suicidal attemps, World Health Organization has chosen Depression as theme for 2017 World Health Day.
Psychiatric illnesses are fundamentally no different from medical illnesses. Historically, illnesses in which there was prominent disturbance of psychological function or behavior and no obvious pathology came to be regarded as ‘psychiatric’. However, we now know that there is demonstrably altered brain function in many psychiatric disorders. We also know that psychological disturbance is common in medical illness. Hence regarding psychiatric illness as ‘mental’ as opposed to ‘physical’ is incorrect. Psychiatric illness is no less real or less deserving of care than are medical conditions.
Diagnosis in psychiatric, as in much of medicine, is based mainly on identifying recognized patterns of subjective symptoms. These symptoms involve abnormalities of behavior, mood, perception, thinking and intellectual function. When severe, these abnormalities may lead to patients being a danger to themselves or to other people. This is recognized in law, and the Mental Health Act gives doctors the authority to treat patients against their will in these cases. However, the great majority of ‘psychiatric’ patients are managed in general practitioners’ surgeries, mental health centers or hospital outpatient clinics in much the same way as patients with any other medical condition.
The average general practitioner (GP) can expect to be consulted by 1 in 7 of his or her patients each year because of a psychiatric disorder. Physicians and GPs see a greater proportion of patients with neurotic illnesses and relatively few with psychotic illnesses; their patients are less severely ill than those attending a psychiatrist, and are more likely to present with somatic bodily complaints. Phevalence of psychiatric illness in different populations are; in community 15-20%, in general practice attenders 30% where as, in general hospital outpatients 20-30%, and general hospital inpatients 25-40% respectively.
No doubt, depression is only one of the multiple major manifestations of psychiatric illness. Some of the other major manifestations include disturbed and aggressive behavior, anxiety symptoms, deliberate self-harm and suicidal ideation, alcohol misuse and withdrawal, misuse of drugs other than alcohol, medically unexplained physical symptoms and functional body syndromes and chronic progressive diseases with mental involvement.
During my assignment as United Nations Volunteer Medical Officer (UNVMO, UNDP) abroad, encountered quite a number civil war victims suffering from Post Traumatic Stress Disorders (PTSD) with suicidal ideations.
Perhaps suicidal attempts are the worst outcomes of depression most of which are fatal.
Presumable causes of depression and mental illnesses are numerous. Genetic factors play an important role, such as a higher prevalence among first-degree relatives than in the general populations; a higher concordance rate in twins, even if the twins have been reared apart; a higher prevalence rate for children of mentally ill parents who are brought up by healthy adoptive parents.
Family background also plays a decisive note. Many patients with psychiatric disorders report an unhappy childhood and it seems likely that a traumatic upbringing predisposes to future psychiatric illness. Important factors are loss of a parent in childhood, due to either death or separation, parental disharmony and physical, especially sexual, abuse. Physical illness and chronic ill health too precipitate mental health. Both predispose to psychiatric disorder. There is an especially well-established link between brain injury and subsequent depressive illness. Physical illness of acute onset can give rise to psychiatric disorder due either to its effect on brain anatomy and physiology or to its emotional significance and implications for the patient’s future well-being.
Stressful life events also give rise to mental illnesses in vulnerable people. They usually involve a sense of loss or threat of loss, and include death of a close relative, marital breakdown, redundancy, retirement and major financial crisis. Social isolation leads to psychiatric problems. Many psychiatrically ill patients are socially isolated and this often appears to be a contributory factor in their illness. Particularly important is the lack of a close, confiding relationship. Social deprivation is associated with various conditions, such as attempted suicide, alcoholism and drug dependence.
Some Internally Displaced Persons (IDPs) were in touch with me when I was appointed as Medical Superintendent at General Hospital Myitkyina, Kachin State. As a health care provider, I noticed stress and strain, physical illness and chronic ailments which led to psychiatric health problems among community. Depression is present in a quarter to a half of all medical patients.Depressed mood is usually a consequence or adverse circumstances in vulnerable persons.
Many cases of depression in medical settings are missed. It is therefore important to ask all patients about symptoms. Depression is the main risk factor for suicide and patients with depression should be asked about suicidal ideas and plans. The first step in managing depression is to find out the patient’s concerns and provide an appropriate explanation and reassurance where possible. For example, it may emerge that he or she has an unjustifiably negative understanding of prognosis or treatment. If depression is persistent, specific treatment should be considered.
Deliberate self-harm (DSH) is a very common reason for presentation to medical services. The term ‘attempted suicide’ is potentially misleading in that the majority of patients are not inequivocally trying to kill themselves. Most suicide attempts involve overdose, either of prescribed or non-prescribed drugs. Other less common methods include wrist-slashing, asphyxiation, drowning, hanging, jumping from a height or in front of a moving vehicle, and using firearms. Methods which carry a high chance of being fatal are more likely to be associated with serious psychiatric illness. There was a steady increase in hospital admissions for suicide attempts from the early 1960s so that by the end of the 1970s there were over 100 000 admissions annually in the UK. (The trend varies between countries). Since then there has been a slight decrease but attempted suicide is still one of the most common reasons for acute medical admission.
Suicide attempts are more common in women than in men, and in young adults than in the elderly. In contrast, completed suicide is more common in men and in the elderly, although there has recently been an increased rate of suicide in young adults. There is a higher incidence of suicide attempts among the lower socio-economic groups, particularly those living in crowded, socially deprived urban areas. Patients often have a deprived family background due to early loss of a parent through death or separation. There are also links with alcohol misuse, child abuse, unemployment and recently broken relationships.
Wish you all a very happy and prosperous new year and complete physical, mental and social well being free from depression.

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