Today, depression is divided into unipolar and bipolar. Monopolar is a common depressive disorder – when an episode of depression occurs once or recurs during a lifetime. It is important that apart from episodes of depression, nothing else happens to the mood.
If we are talking about bipolar affective disorders – in addition to episodes of depression, there must be episodes of either hypomania or mania – these are periods of high mood and energy, with unrestrained communication, spending money, believing in one’s unlimited possibilities. In some cases of bipolar affective disorder, there is a simultaneous presence of symptoms of depression or hypomania / mania – the so-called mixed episode.
They also share chronic affective disorders that last for more than two years. They can be either purely depressive, in which case they are called dysthymia, or contain mood swings from high to low, in which case they are called cyclothymia.
– And can, on the contrary, only episodes of high mood occur, without depression? And what is it called then?
Psychiatrists of the last century observed some rare cases when a person could only repeat hypomanic or manic episodes. Today it is believed that this refers to bipolar affective disorder, because sooner or later the opposite pole appears – depressive or mixed episodes.
“Under depression, ordinary people understand just a sad mood. At what point does it become a mental disorder?
– If we talk about the diagnostic criteria by which a doctor in Russia , a doctor in Germany, a doctor in China will speak of depression as a clinical biological disorder, then a set of conditions must be observed. The first is a lowered mood, and most of the day, which lasts at least two weeks. Further, the main symptoms include fatigue: usually it bothers a person in the morning – he does not feel rested after sleep. Another important criterion is the loss of pleasure from what previously gave pleasant emotions, which is denoted by the term anhedonia. These are the basic main symptoms of depression as a biological disorder. But there is an additional set of symptoms.
– For example?
– Pessimistic assessment of one’s prospects, suicidal thoughts, difficulty making decisions, concentrating, poor sleep (most often early morning awakening), poor appetite, weight loss.
– You are talking about clinical manifestations that you learn about during a patient interview …
And not only the patient, but also his relatives.
Sometimes five minutes of communication with a patient’s relative gives more than an hour of conversation with him, this is especially important when diagnosing hypomania or mania, when the patient himself may not consider that he has any problems.
But there are also behavioral aspects that may suggest that we are dealing with a depressive disorder. In such cases, we observe special behavioral reactions, a kind of pantomime, for example, poor gestures, a special gait, facial expressions – even certain wrinkles on the face can indicate that, most likely, we are talking about sadness, melancholy, low mood.
Also, depression is characterized by a certain timbre of the voice, the rate of speech, gaze, the ability to make eye contact with the interlocutor, etc.
– Is there a biochemical analysis that could determine depression in a person?
– It would be great to have an analysis similar to what is possible in diagnosing diabetes, when, by the content of glucose in the blood, one can more or less reliably say whether a person has diabetes or not. But
in depressive disorders, unfortunately, absolutely reliable and unconditional biological indicators do not exist.
Now there are really a lot of studies on this subject, they find new markers. But so far, as before, to a greater extent we rely on clinical signs, behavioral, physiological manifestations. However, it is clear that future advances in more reliable diagnosis of psychiatric disorders are associated with the simultaneous use of both clinical signs and certain panels of biomarkers.
— That is, modern psychiatrists do not use these markers in practice at all?
“Biological markers are still more important not so much for diagnosis as for evaluating the effectiveness of ongoing therapy. Sometimes in the course of treatment there is a formation of resistance to drugs and measures must be taken to intensify therapy.
– And what do you need to take to understand if the treatment helps?
— An example is the assessment of the level of BDNF (brain-derived neurotrophic factor), a brain-derived neurotrophic factor that controls the development and interaction of neurons and conditionally shows how successfully the nervous system functions. There are foreign and Russian studies, including those conducted at our institute, which say that if this factor increases, antidepressant treatment can be assessed positively.
Is this a blood test?
– Is there really a study going on at your institute that will allow you to distinguish unipolar depression from bipolar depression by a blood test?
– Yes it is.
Why is it necessary to distinguish them?
“We need a different kind of therapy. What is the problem? The correct diagnosis of “bipolar affective disorder” is made on average ten years from the onset of the disease. And this disorder often begins only in the form of depressive episodes. Doctors consider this unipolar depression and use antidepressants, often for quite a long time. And this leads to an increase in affective episodes and, ultimately, worsening of undiagnosed bipolar affective disorder.
What should be written in this case?
– If we are talking about bipolar depression, then the preferred drugs are the so-called mood stabilizers – mood stabilizers, as well as atypical antipsychotics.
What could indicate bipolar depression before it began to alternate with hypomanic or manic episodes?
– There are supporting clinical symptoms that say that the current depression is highly likely to be bipolar. These symptoms can be, for example, atypical depressive symptoms, when drowsiness increases instead of insomnia in typical depression, appetite increases instead of loss of appetite, weight increases, emotional lability appears – when, along with a depressed mood, a positive response to some aspects of the surrounding life can remain. Predominant psychomotor retardation, the presence of psychotic symptoms, a very early onset of the disease – earlier than 20-25 years old – are also serious signs that we are most likely facing a patient with bipolar depression, although formally he has not yet had hypomanic, manic or mixed symptoms. This is also indicated by the very frequent repetition of depressive episodes,
– How can one understand from the behavior of the patient that he has depression of a “different kind”?
– Often doctors are faced with the fact that they prescribe an antidepressant during a formally ongoing depressive episode and suddenly see that the patient becomes agitated, agitated, more talkative, sleeps less, becomes more energetic. Or he improves very quickly – on the second or third day, which does not happen with classical antidepressant therapy, this usually happens at a later date – at least 10-14 days or more. This happens just in the case of latent bipolar depression. The appointment of antidepressants, relatively speaking, exposes bipolarity.
– Why can’t unipolar and bipolar depression be treated with mood stabilizers? They should in any case stabilize the state?
Each drug has its own profile of action. It is assumed that
with unipolar and bipolar depression, different biological mechanisms of development are used, therefore, different therapeutic approaches are used.
In unipolar depression, after the person’s condition has stabilized, we can recommend taking antidepressants for a long time, in some cases for life. With bipolar depression, we cannot give such a recommendation, because it will destabilize the course of the disease. The doctor must clearly understand this.
– Are there any depressions that are not treated at all?
– Unfortunately yes. If we talk about statistics, according to large epidemiological studies, 10-12% of patients who once fell ill with depression never recovered from it.
– Antidepressants or mood stabilizers do not help them at all?
– It’s different here. There are situations when they do not help at all, there are situations when they help, but not so well that it satisfies the patient and the doctor.
– Is depression treated in our country with the help of deep brain stimulation?
“Stereotaxic surgeries involving the insertion of thin microelectrodes directly into the brain, namely into the parts of the brain that are involved in the regulation of emotional life, followed by the supply of electrical stimulation to these brain structures using a special electrical stimulator, are indeed carried out in some countries.
In Russia, as far as I know, this kind of treatment for depression is not used. There are various reasons for this. On the one hand, there can be major changes for the better, but these invasive surgeries can also bring serious problems. For example, during the operation, a cerebral vessel may be damaged, bleeding may begin, which can then adversely affect the surrounding brain tissues. An epileptic seizure may occur due to microdamage to important areas of the brain, and subsequently these damaged brain structures can begin to generate epileptic seizures.
It should be emphasized that such operations are performed only in cases where various methods of depression therapy have been unsuccessful and when all possible risks have been comprehensively assessed. In some neurosurgical centers in Russia, this method of treatment is used, for example, in Parkinson’s disease.
There are other ways to improve treatment-resistant depression. For example, stimulation of the vagus nerve (vagus stimulation), when a special electrical impulse generator is implanted into the subcutaneous tissue of the chest, from which the thinnest electrodes are connected to the left vagus, is one of the major nerves of the parasympathetic nervous system, which is interconnected with different parts of the brain responsible for emotional regulation. Such operations are carried out in Russia. In general, a number of non-pharmacological treatments are used in the treatment of resistant depression, each with its own advantages and disadvantages.
– Now many people are depressed because of the political situation, worried about loved ones. Many are below average. At what point should they realize that they really need to go to the doctor?
– In the age of digitalization, there are a lot of questionnaires that are evaluated as screening. A person can find these questionnaires on the Internet, fill them out. The questionnaire, of course, is not a diagnostic tool, but it works on the principle of a mine detector – it can work, relatively speaking, both on a tin can and on a real mine.
If the questionnaire gives the result: “You should contact a specialist,” this is an occasion to think about such a visit.
People can also share their experiences with a general practitioner, neurologist or other specialist who can better assess the situation and advise you to contact a psychotherapist or psychiatrist.