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OF mental health care and mentally ill

The manifestation of depression

Depression has a range of meanings – from a description of normal unhappiness, through persistent and pervasive ways of feeling and thinking, to psychosis. According to World Health Organization data, depression affects about 50 million people and causes about 10% of the global burden of disease worldwide, with women and economically impoverished people being affected disproportionately.

By 2030, depression is projected to be the second greatest cause of years lived with disability worldwide. Textbook descriptions of depression seen in hospitals are often very different from presentations in primary care. In recent community surveys, 2% of the adult population suffered from pure depression (evenly distributed between mild, moderate and severe), but another 8% suffered from a mixture of anxiety and depression.

Even patients with symptoms not severe enough to qualify for a diagnosis of either anxiety or depression alone have impaired working and social lives and many unexplained physical symptoms, leading to greater use of medical services. Variable presentation of depression, particularly in primary care, may make recognition and diagnosis difficult. Recent guidance by the National Institute for Health and Clinical Excellence (NICE) has suggested that patients with risk factors or previous history should be screened routinely using standard questions, or questionnaires such as the PHQ-9. Key practical questions relate to treatment: is any required at all and, if so, what sort, and for how long?

Depression is one of the major causes of disability worldwide

There are several forms of depressive disorder, but clear criteria exist for diagnosis (presence of specific features for at least two weeks)

Moderate depression, sufficient to prevent normal functioning, responds to both antidepressants and cognitive behavioural therapy; severe depression may require additional antipsychotic medication

Depressive episodes are often under-treated: too low a dose of antidepressant for too short a time, or changing drugs too frequently

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