Psychological management of depression

by Dr. R.A.R.Perera

Depression is such a common experience that everyone encounters it at some time in his or her lives.

Its relationship to anxiety is close and anxiety tends to proceed to depression to follow an unpleasant experience. Sometimes the depression is clearly outside the limits of normality and we regard it as an illness.

There are two main depressive illnesses.

Neurotic or reactive depression in which the gloominess or sadness described by the person follows some significant event but the misery and grief are out of proportion to it in intensity and duration.

The second is endogenous depression, which is more severe. It occurs more in females (3:2) and is genetically determined.

Surgery

The term 'masked depression' is sometimes used when somatic features predominate; the patient sometimes denies depression although careful questioning reveals the true state. Such cases are frequently misdiagnosed and subjected to intense and unnecessary investigations and surgery.

Neurotic depression usually comes on abruptly in relation to an unpleasant occurrence. It could be explained as a loss event experienced by the patient and his sensitivity to minor stress and other evidence of a predisposed neurotic personality. The first episode usually occurs in early adult life. The patient feels miserable and unhappy and expresses self-pity, often displaying as much anxiety as depression.

The symptoms fluctuate in response to daily events, often tending to become worse torwards evening. The patient becomes tearful, feeling helpless and hopeless, clearly expecting sympathy for a condition, which is beyond his control and for which he is not responsible.

Concentration is impaired and the patient easily becomes fatigued.

A wide variety of symptoms like headache, stomach problems, reduced appetite and weight loss could be present. Sleep disturbance is usual, typically waking up early in the morning (eg 2-3 am) and inability to fall asleep after that. Suicidal ideas and attempts are common.

Many cases of neurotic depression last only days or weeks.

The nature of provocative event is important. If for example, this is some insoluble interpersonal conflict the illness may persist indefinitely.

The final outcome depends on whether the precipitating problem can be resolved and on the nature of the patient's personality.Endogenous depression differs from neurotic depression qualitatively.

In practice the distinction is often difficult to make because the person may react, as to other life-disturbing event.

Difference

If the depression is mild, the person may not appreciate that he is ill and may not seek medical help.

But observant friends and family members will notice the difference. Patients with moderately severe depression are more likely to seek medical help. The illness usually develops gradually over a few days or weeks.

His interests become restricted or lost, concentration is impaired and his thoughts are often dominated by feelings of guilt and unworthiness.

In some patients he is concerned that he may have some serious physical ailment, particularly cancer or heart disease.

The face will show a sad expression but may still smile deceptively so that the correct diagnosis is not made. Fatigue and loss of energy are marked and in many cases sleep is disturbed with restless and early wakening. Weight loss up to 5kg, suicidal thoughts varying in intensity from the feeling that if by chance one died it would not matter, to the conviction that death is the only way to obtain relief. Sexual desire is reduced, constipation is frequent (and menstruation becomes irregular). In severe cases the patient becomes immobile, mute, and will refuse to eat. This endogenous depression may last from 6-8 moths to many years.

Many drugs, which are taken for high blood pressure and contraceptive pills, can cause depression. Some fevers infective hepatitis and some cancers (cancer of the pancreas) can cause depression. Sometimes dementia (forgetfulness) can show as a depression.

The majority of depressed patients can be treated as an outpatient. Admission as advisable if the depression is severe, if suicide is likely or if an organic illness is suspected. A patient living alone requires admission for a milder illness than one who has a supportive and sensible family. If he is able to continue working he should be encouraged to do so. Although it is important to reassure him that he will get better.

It is vital that this should be done sensibly. He should certainly not be told that all he needs is a quiet holiday. This may well have an adverse effect, causing him to lose faith in his caregiver and to conclude that suicide is the only answer.

Psychotherapy and antidepressant medications are the most useful methods to treat depression.

In many cases social problems and environmental difficulties should be corrected and a social health worker is most helpful in these circumstances. ECT or Electro Convulsive Therapy is used if the depression is severe and if it endangers the life of the patient. This is an effective and fast acting treatment. Following ECT, patients may experience headache and muscle pain, but they are mild and short-lived.

A regular walking regimen can benefit some cancer survivors

Researchers have affirmed that pancreatic cancer patients can literally take a step-by-step approach to combat fatigue. A study published in the April issue of the Journal of the American College of Surgeons reports that patients who underwent an operation as part of their cancer treatment and then started a regular walking regimen experienced less fatigue than cancer survivors who did not do the walking program.

It is estimated that each year, approximately 50,000 people are diagnosed with pancreatic or periampullary cancer. The latter forms near the ampulla of Vater, an enlargement of the ducts from the liver and pancreas where they join and enter the small intestine, according to a definition put forth by the National Cancer Institute (NCI).

The NCI reports that chronic fatigue affects up to 96 percent of people being treated for cancer. It's so common that "sometimes it's overlooked as normal and people tend to write it off," said the study's lead author Theresa P. Yeo, PhD, MPH, MSN, associate professor of nursing at the Thomas Jefferson University School of Nursing, Philadelphia, and associate director of the Jefferson Pancreas Tumor Registry at the hospital's department of surgery. "But this is not the normal 'I-stayed-up-too-late' fatigue. It's really being exhausted, and it doesn't go away with sleep. It hits patients in their daily activities - simple things like doing your personal hygiene in the morning, getting up and getting dressed, going from the bedroom to wherever you eat breakfast."

This type of fatigue can also lead to anxiety and depression.

Dr. Yeo and colleagues recruited 102 patients who had undergone surgical resections for pancreatic or periampullary cancer. Most study participants were Caucasian men and women aged 66 or 67 years old with Stage IIA or Stage IIB cancer. The patients also had similar rates and types of chronic conditions, such as hypertension or diabetes but no conditions that could severely limit mobility. The patients were randomised into two groups just before hospital discharge: The usual care group went home with normal discharge instructions that did not include a walking or exercise routine. The intervention group was charged with walking for increasingly longer intervals each week for three months. The first month, for example, included walking sessions for 20 minutes with five minutes to warm up and five minutes to cool down. "But if people could only walk for three minutes, we said start with that and work your way up," Dr. Yeo explained. If patients felt any discomfort or shortness of breath while walking, they were instructed to slow down or stop. The goal was to increase walking time 90 to 150 minutes each week by the end of the three month program.

Patients in the walking intervention group mailed in monthly logs of their walking durations and distances. Each month, researchers followed up with patients in the walking intervention group to ask a set of outlined questions about their medical condition, adherence to the walking program and their current fatigue and pain level, along with other symptoms such as diarrhea insomnia or depression.

Researchers contacted all patients after three months for final reports on fatigue level using standardized survey tools. At the beginning of the study, 85 percent of all patients reported moderate to severe fatigue.

Three months after discharge, the intervention walking group reported a 27 percent improvement in fatigue, compared with a 19 percent improvement in the usual care group. The intervention walking group also reported greater improvements in experiencing less pain than the usual care group.

"The beauty of this program is that we're not asking for high intensity aerobics or a target heart rate," Dr. Yeo said.

"It's low to moderate intensity and they can sit if they need to. They don't have to push through it if they are not feeling well that day."

Though the study authors acknowledge that more research is needed, patient discharge instructions have already been changed at Thomas Jefferson University Hospital to encourage walking or some form of aerobic activity as patients recover.

She added that walking is accessible to everyone, whether they go to a gym, a local mall or just walk around the house several times a day to build stamina."The message in pancreatic cancer care has typically been that these patients are just too sick to do this, but that's not true anymore," Dr. Yeo explained. "With increased surgical expertise and the use of postoperative critical care pathways [care maps], more patients are feeling better sooner and going home earlier after their operations.

There is no reason that patients can't become active, even if they did not exercise before.

- eurekalert

Chronic stress linked to many diseases

Stress wreaks havoc on the mind and body. For example, psychological stress is associated with greater risk for depression heart disease and infectious diseases. But, until now, it has not been clear exactly how stress influences disease and health.

A research team led by Carnegie Mellon University's Sheldon Cohen has found that chronic psychological stress is associated with the body losing its ability to regulate the inflammatory response. Published in the *Proceedings of the National Academy of Sciences,* the research shows for the first time that the effects of psychological stress on the body's ability to regulate inflammation can promote the development and progression of disease.

"Inflammation is partly regulated by the hormone cortisol and when cortisol is not allowed to serve this function, inflammation can get out of control," said Cohen, the Robert E. Doherty Prof of Psychology.

Cohen argued that prolonged stress alters the effectiveness of cortisol to regulate the inflammatory response because it decreases tissue sensitivity to the hormone. Specifically, immune cells become insensitive to cortisol's regulatory effect. In turn, runaway inflammation is thought to promote the development and progression of many diseases.

Cohen, whose groundbreaking early work showed that people suffering from psychological stress are more susceptible to developing common colds, used the common cold as the model for testing his theory.

With the common cold, symptoms are not caused by the virus - they are instead a "side effect" of the inflammatory response that is triggered as part of the body's effort to fight infection.

The greater the body's inflammatory response to the virus, the greater is the likelihood of experiencing the symptoms of a cold.

"The immune system's ability to regulate inflammation predicts who will develop a cold, but more importantly it provides an explanation of how stress can promote disease," Cohen said.

"When under stress, cells of the immune system are unable to respond to hormonal control, and consequently, produce levels of inflammation that promote disease.

Because inflammation plays a role in many diseases such as cardiovascular, asthma and autoimmune disorders, this model suggests why stress impacts them as well."

He added, "Knowing this is important for identifying which diseases may be influenced by stress and for preventing disease in chronically stressed people."

- MNT

Slow wound healing in women may be due to oestrogen

Oestrogen causes wounds in women to heal slower than in men - who have lower levels of estrogen - says a new study published in the FASEB Journal. In the report, scientists from the University of California, Berkeley, provide the first evidence that mild injury response in the eye is fundamentally different in males and females because of estrogen. This discovery provides new clues for successfully treating a wide range of inflammatory diseases such as dry eye disease, rheumatoid arthritis lupus multiple sclerosis and scleroderma

"We hope that our finding will spur research efforts into delineating sex-specific differences and estrogen regulation of intrinsic circuits that determine the outcome of healthy and routine injury responses," said Karsten Gronert, a researcher involved in the work from the University of California. "Auto-immune diseases in general are not triggered by a single event; hence, understanding what leads to a recurrent dysregulation of fundamental injury responses may help us treat and/or prevent the development of female-specific diseases."

To make this discovery, Gronert and colleagues administered a mild abrasion injury to the front of the eye of genetically similar male and female mice, and analysed wound healing by image analysis. To test the role of oestrogen, they gave male mice estrogen eye drops and/or drugs that activate specific oestrogen receptors. Gene expression of essential enzymes was quantified for the formation of protective lipid signals, specific receptors that mediate their bioactivity, as well as estrogen receptors in mouse corneas and human/mouse epithelial cell cultures. The formation of protective lipid signals was analysed by a mass spectrometry based lipidomic method. They found that estrogen negatively affects a highly evolved protective lipid circuit, called "15-lipoxygenase-Lipoxin A4" that has recently emerged as an important protective pathway in many diseases. - Topix.com

Surgery cuts costs for children with perforated appendicitis

Paediatric surgeons can lower health care costs if they remove a young patient's perforated appendix sooner rather than later, according to new study results published in the April issue of the Journal of the American College of Surgeons.

Acute appendicitis which can precede a perforated appendix, disproportionately affects young people ages 10 to 19. However, the condition is more likely to progress to a perforation in children younger than age 4, according to previous research findings. It is estimated that approximately 77,000 children are hospitalised for appendicitis and similar conditions each year, and one-third of them will have a perforation before having an appendectomy, the operation performed to remove the appendix.

Diagnosis

The study authors found that hospital charges for children who had a perforated appendix removed 24 hours after diagnosis were about $10,000 lower than charges for children who had the surgical procedure six to eight weeks later, after first being treated for abdominal infections and contamination from the perforated appendix. Hospital costs for the patients who were treated early were approximately $5,000 lower than those who underwent an appendectomy at a later time.

One primary reason for the lower costs was that early appendectomy patients had better clinical outcomes and fewer adverse events. Though both treatment approaches are common, "we hypothesised that the early surgical procedure would be better. In the trial, everyone is getting the same therapy - they're getting the appendix out. It's just a difference of when the operation happens," explained Martin L. Blakely, study author and associate professor of surgery and pediatrics. "Initially, we said that even if the clinical outcomes turned out to be the same, we need to know if costs are different."

Between October 2006 and August 2009, Dr. Blakely and fellow surgeons randomised 131 paediatric appendicitis patients at LeBonheur Children's Hospital, Memphis, Tenn., into two groups: One group was assigned to receive an early operation after diagnosis of perforated appendicitis, while the other would undergo the procedure up to eight weeks after diagnosis.

The five participating surgeons performed the appendectomy according to the patient's randomisation group. Each participating child's resource usage and cost data, including labor costs, supplies, facility services, and patient support services (ie: nutrition social work, and family support) were then collected and analyzed.

Analyses also included administrative and overhead costs, such as medical records management, information technology, admissions, and billing procedures. Patients who underwent the later appendectomy (interval appendectomy) received more medical interventions than those who had the early appendectomy.

Later appendectomy patients stayed in the hospital two days longer, and 87 percent received a central venous catheter, compared with only 44 percent of patients who had the early operation. Of all patients who received catheters, 43 percent of later appendectomy patients were discharged with it, compared with only 9 percent of early appendectomy patients.

Dr. Blakely said the biggest contributor to higher costs of delaying the operation was the increased likelihood of delayed appendectomy patients having an adverse event, such as an intra-abdominal abscess or an intestinal blockage. These adverse events, which led to emergency room visits and unplanned readmissions, more than doubled hospital charges and costs.

Operation

The authors found that 30 percent of the early appendectomy patients had an adverse event, compared with 55 percent of those who had the operation at a later time.

"Surgeons decide based on their training or what they are used to doing. Maybe one surgeon came from a place where they only did interval [later] appendectomies, but another surgeon only did early appendectomies.

So, the specific surgical plan of care patients get can, to some extent, depend on what day they show up," Dr. Blakely said.

"Currently, we're being stimulated to compare the available surgical therapies with regard to outcomes and costs by various regulatory agencies. As we move toward practicing evidence based medicine and surgery, it's our responsibility to our patients to study the available therapies so we can tell families which approach is more clinically sound and cost effective," he concluded.

- medicalxpress