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About therapy for severe depression

«Severe depression» most commonly seen in recurrent depressive disorder (recurrent depressive disorder) or bipolar disorder (manic-depressive psychosis), in the United States it is often called «major depressive disorder». Neurotic depression can also manifest «severe depression», but usually within the context of mixed anxiety and depressive disorder. «Severe depression» occurs with organic brain damage, for example, a pineal gland tumor that produces the hormone melatonin, or with a hormonal disease, for example, the thyroid gland.

Rod sign «severe depression» considered anhedonia — a condition in which a person does not enjoy what he received before. «Severe depression» also manifests itself in irritability, anxiety, melancholy and apathy, and the older the person, the more melancholy and apathy, the younger — irritability and anxiety.

For «severe depression» typical: self-accusations, decreased self-esteem, indecision, feelings of hopelessness and hopelessness, loss of interest in life and thoughts of suicide. The danger of the latter increases with an increase in the level of anxiety and excitement, the appearance of panic attacks against this background. «Severe depression» are accompanied by impaired memory, attention and thinking, the latter becomes inhibited, it is difficult for a person to collect thoughts and concentrate.

In addition, sleep is disrupted in severe depression (80% of cases — these are early awakenings, in 20% — drowsiness and lethargy during the day; usually decreased appetite, weight loss, severe constipation.

«Severe depression» does not occur very often, usually depressive episodes are moderate–pronounced character, but, unfortunately, acquire a protracted course, especially with improper treatment and in old age.

Despite the prevalence of depression, little is known about it and its danger is underestimated. Depression — this is «invisible disease», they say little about him, and rarely go to the doctor. Even in the United States, where psychiatry has long since ceased to be something of a shame and has become as commonplace as a visit to the dentist, up to 37% of patients with severe depression do not receive the necessary treatment (Shim, 2011).

Why depression is dangerous?

Depression is associated with an increased risk of cardiovascular disease and impaired immune system (higher risk of inflammatory, infectious, and cancer). In general, according to the latest data, depression is always accompanied by a fairly strong inflammation..

As noted earlier, «severe depression» often accompanied by suicidal thoughts. In fact, there are many reasons for suicide, but not all of them, of course, are associated with «severe depression», sometimes they happen against the background of alcohol intoxication, in old age, with the loss of a partner with whom a person has lived all his life, etc..

In the United States, an average of 44,000 people commit suicide a year. In northern countries there are more suicides than in southern countries, at a young or old age, especially men, more often commit suicide.

Most suicides could have been prevented if a depressed patient or family member sought help on time. Why isn’t this happening? A person with severe depression rarely seeks help on his own. The future for him is presented in a negative light, he does not believe that someone can help. Even when he has suicidal thoughts, it seems like a natural continuation of depression. The patient rarely speaks of suicidal intentions at the time they first appeared. Sometimes relatives can learn about thoughts of suicide of a sick person only on indirect signs. — the sudden distribution of personal belongings, talking about death, or looking for funds for suicide. Note that suicidal thoughts — indications for involuntary hospitalization in a psychiatric clinic.

Relatives often do not notice even very severe depression in loved ones, especially if the sick person spends a lot of time at work or school, or lives separately. Many hide depression as a sign of unhappiness and choose not to talk about their problems..

How to understand that a loved one is thinking about suicide?

Such statements as «i don’t want to live», «it will be easier for you without me», «nobody cares if I live or die», must always be taken seriously. Parents often assume that adolescents are manipulating the theme of their death. This does not happen as often as suggested, but even with manipulation, there is a great risk. «play too».

It is believed that someone who talks a lot about suicide never actually commits it. It is a myth. The constant recitation of the topic of suicide, and especially the means of suicide, brings the patient closer to action. Relatives, seeing the symptoms of depression, the prolonged depression of the patient, are afraid to ask directly whether he is thinking about suicide. Many believe that such a question can lead to suicide. This is another myth. It is important to understand what happens to someone with depression and how severe his condition is. Open conversation — the best option to clarify the situation, therefore, psychiatrists often directly ask the patient about the presence of suicidal thoughts, believing that this postpones the possibility of suicide.

Inpatient treatment for severe depression

If your loved one has thoughts of suicide, I recommend urgent hospitalization in the hospital despite the patient’s refusal. This position may seem like an unnecessary precaution, but I have seen enough cases when the decision to attempt suicide was made almost instantly and was completely unpredictable (the patient’s condition «flickers»). Severe depression — it is a disease that seriously affects thinking.

As I wrote earlier, if you think that a sick loved one is reasonable enough and in control of himself, you are mistaken. Studies of the brain’s response to certain stimuli (cognitive evoked potentials) show that a person with severe depression spends on average 1.5-2 times more time on processing information than a healthy person. Depression seriously affects the brain, destroying it and this effect should not be underestimated.

On the other hand, drugs prescribed for depression, antidepressants, do not act immediately, and in some cases they can increase suicidal thoughts, especially when prescribing drugs that selectively affect serotonin, for example, a drug such as Sertraline. Sometimes, with severe depression, the patient does not have the energy and strength to attempt suicide, but at the beginning of treatment and a slight improvement in his condition, the patient attempts to commit suicide. In my book «Depression» I write about such cases.

In general, outpatient treatment for severe depression seems to me to be risky and unjustified. If you do not have the financial ability to treat a loved one in a private clinic, it is better to go to a public hospital, but not risk trying to get treatment at home. For persistent suicidal thoughts, antipsychotics are prescribed, more often Clozapine and even electroconvulsive therapy, which, for example, took place with the writer Hemingway.

Drugs and TMS in the Treatment of Depression

Antidepressants are traditionally prescribed for any depression, however, at least 30% of depressed patients do not respond to antidepressants and should be treated with other methods and drugs, for example, cognitive — behavioral therapy, weak currents that stimulate specific structures or transcranial magnetic stimulation, mood stabilizers, NMDA receptor blockers, or antipsychotics.

We select the drug based on the severity of the condition, the risk of developing bipolar disorder (drugs that affect only serotonin receptors cause the so-called «phase inversion», contributing to the appearance of manic states), as well as data from pharmacological genetic analysis. In our clinic, the content of the drug in the blood is monitored to avoid overdose and the development of side effects and the use of low dosages that do not give the desired therapeutic effect.

In addition to drugs, we use the method of transcranial magnetic stimulation (TMS), which is approved for the treatment of depression by the English NICE and the American Psychiatric Association, as well as other methods of physiotherapy (nasal electrophoresis, neurobiomodulation, instrumental psychotherapy, etc.)

Psychotherapy in the treatment of depression

Psychotherapy — an important part of depression therapy. All over the world, a cognitive-behavioral approach is used, which has proven its effectiveness in a multitude of studies. Psychotherapy for «severe depression», if it is carried out by a psychologist, it should go under the supervision of the attending physician — psychiatrist. The duration of psychotherapy varies, usually about 15 to 30 sessions are needed to achieve a lasting result. A large number of sessions seems to me pointless and even harmful, because the patient begins to develop dependence on therapy and on a psychotherapist.

Relapses of depression

With improper or incomplete treatment of depression, the disease in most cases returns again, in 50% of cases — within 6 months, in 85% of cases — within 10 years after the first episode of depression (Forte et al., 2015). These numbers suggest that it is imperative to properly and completely treat a depressive episode..