Traitement dépression
There are effective treatments against depression. They may be based on psychotherapy and / or drugs. Treatment should be determined in consultation with the patient. It takes about six months, and will take place as an outpatient. The most serious cases will be treated in hospital.
Antidepressants act on neurotransmitters in the brain. It is generally assumed that increasing the amounts of neurotransmitters (especially serotonin), which restores the chemical balance disrupted in depression. They usually act within 10 to 15 days, he must wait two to three weeks minimum treatment before judging the effectiveness of a molecule.
One of their main effects is to remove the inhibition (before treating depressed mood), which may paradoxically encourage the transition to a suicidal act. Therefore the start of treatment, an anxiolytic is often prescribed in combination with the antidepressant.
It is a treatment based on the principle of regular meetings. It may take several months to years.It can be practiced by a psychiatrist, psychologist, doctor or not a psychoanalyst.
It involves an awareness and a voluntary approach from the depression. Help support the patient psychologically for the depressive episode, and help to better understand his depression. Thus it also prevents recurrence. Psychotherapy alone may be sufficient in some slight depression, in other cases it will combine antidepressants and psychotherapy.
Drug therapy plays an important role in the management of bipolar patients. Meanwhile, the dissemination of detailed information about the disease and its treatments, the development of psycho-educational measures, the rules of life, initiation of psychotherapy, participation in discussion groups, will complete support.
The salt treatment is the treatment the oldest and the most specific characteristic of bipolar disorder.They are officially listed in the curative treatment of manic states. However, the delayed onset of action involves the joint use of neuroleptics in manic states characterized.
United States, lithium salts are the only ones to have the official indication in the prevention of recurrence. Their prescription remains limited in France because of unwarranted fears about their toxicity and their terms of limitation. They reduce the risk of suicide (10 to 6 times less according to studies) and lower the mortality rate that is identical to that of the general population.
The cons-indications are rare. Kidney malfunction, severe cardiac disorders, a low salt diet, prescription diuretics are cons-indications. Pregnancy requires special measures. The decision to continue treatment with lithium salts in a pregnant woman depends on the severity of previous episodes, history of suicide and risk of avulsion that could cause the appearance of a new episode.This decision will be made jointly with the psychiatrist, the obstetrician and patient. Tolerance is generally good, provided you follow certain rules prescribing and better adjust the dosage of lithium based on numbers of serum lithium levels, that is to say the concentration of lithium in the blood .
Anticonvulsants are preferably indicated in the treatment of mixed states (entanglement of excitation and depressive symptoms in the same episode), shapes rapid cycling (four episodes at least a year), in the absence of family history, and in the so-called secondary forms (where there is an organic cause). It is recommended to use an association with lithium salts in case of resistance. Conventional antipsychotics are commonly prescribed in the cure of a state of manic excitement. It is conventional to restrict the prescription of neuroleptics because of adverse neurological effects and a possible depressogenic effect. Limiting the duration requirement may nevertheless be a factor for relapse.The new generation antipsychotics appear to be more specific to this type of disorder, due to their good tolerance and lack of depressogenic effect.
Drugs mood stabilizers do not always protect against the onset of depressive episodes. Antidepressants may be justified in cases of major depression, knowing that they are exposed to risk turning manic excitation and acceleration of disease cycles. The new generation products (Seroxat, Seropram, Norset …), would expose the patient to a lower risk of provoking a state of excitement.
In psychiatry the term depression (or depression), Latin depressio, ‘draft’ is a relatively recent, it is around the nineteenth century it appeared in its psychological use.
He gradually – in part – supplanted the old term of melancholy which had become ‘lypemania (‘ madness sad ‘) with Esquirol (1819) and’ manic depressive ‘in the late nineteenth century Emil Kraepelin to describe syndromes is now called ‘major depression (bipolar disorder, or mild: cyclothymia, etc..). Note that Kraepelin’s heard mostly in the direction of psychosis with the alternation of manic episodes – or hypomania – and depression.
So far the outset that all these terms are often used to refer to entities that contours are not clearly established.If one adds that the countries where they were not all used the same psychiatric tradition, whether for the terminology or the nature of the disorders described it is understandable that some confusion has not been fully abolished by the new international classification ICD or DSM U.S.. It is not trivial nor absurd to say that – or – depressions in psychiatry today are antidepressants that treat and although this is far from satisfactory in terms of epistemology! Roland Gori wonder how we arrived at the spread of diagnosis ‘depressing’ ranked as one of depression scourges of health at the time. He questions the fact that it has come to a diagnosis which he said is as much related to social norms with the reality of a real entity that would be the depression-diagnosed ‘liquid’ to a civilization ‘liquid’ (…) Perhaps the concept of soft depression is that it hides the misery of this civilization that disavows the value of melancholy? wonders there yet.He goes on to say that beyond a pathology resident in melancholia, the foundations of the subjectivity of the individual.
Special Cases
Depression baby
Tables of severe depression, may develop life-threatening, have been described since 1950 in infants, especially after brutal losses parenting. Rene Spitz has defined hospitalism, state arising from an abrupt separation from parents, going through a phase of whining, then a phase of protest, yelp, rapid weight loss, developmental arrest, then a third phase divestment of the world that surrounds and withdrawal leading to what Spitz called anaclitic depression. This clinical picture may regress if adequate measures are taken quickly. If prolonged, may be the cause of intellectual disability, learning, psychological difficulties, with greater vulnerability to separations, producing paintings deficiency with risk of progression is heavy.
This diagnosis must be made with caution. In particular, the differential diagnosis with disorders related to autism should be considered. It still happens today, a bad clinical depression confuse the baby and autism.
Depressed Child
When discussing depression in children one is struck by the contrast between his frequent reference to the theoretical level – including psychoanalysis – and the scarcity of clinical presentations that do not adultomorphe. It is the psychoanalyst Melanie Klein, who speak one of the first depression of the child in his theory of the depressive position to intervene at weaning, around the sixth month. Melanie Klein’s theory should be well known to be operational in child psychiatry, as well as later in adolescents and adults, depressive symptoms may be the result of a defense against the depressive position, they are not assimilated.Many authors, the pediatrician Donald Winnicott (who spoke to him of worry or ‘compassion’, 1954) has criticized the earliness of this ‘position’ and Margaret Mahler who was between the sixteenth and twenty-fourth month. It then works with Bowlby on attachment who has studied the effects result in separations (which must not confuse with ‘depression’) that partly corroborate the observations of Rene Spitz cited above. When manifested in ways that can be likened to that of adult depression in children is reflected by tears, sadness, boredom, indifference and fatigue. Low self-esteem is expressed through repeated observations: ‘i can not,’ ‘I can not,’ which is also reflected in games and academically. The child feels unloved and unappreciated. Physical symptoms are common, insomnia, anorexia (atypical) stomachaches and headaches. The clinician, in its investigation by clinical interview, dialogue with peers:Parents, teachers and possibly siblings must detect events from indirect signs of possible depression. We may use psychological assessment with projective tests Rorschach, CAT or other. The questionnaires are often not randomized not reported because it marks an exaggerated importance to the verbal in its primary meaning which is not suitable for children.
Furthermore, and unlike adults, depressed child does not complain of sadness or hopelessness, and symptoms are somewhat noisy. A French consensus conference in 1995 helped to clarify the symptomatology and the principles of therapeutic interventions.
The first-line therapies are psychotherapy, including psychoanalysis and family. One and one are often used jointly, it is in the systemic or psychoanalytic approach. The pediatrician’s role is crucial here is the one who first could hear the suffering of his young patient and that can help guide parents at the time specialist.Drug treatment should be indicated by the specialist and the greatest possible use transiently until the child involved in her psychotherapy and if he succeeds. For small children, up to six years of psychotherapy ‘parent-child’ or more commonly ‘mother-child is a big help. An appeal to a specialized center (Day Centre) or any other operations on the environment may prove very effective sometimes.
This diagnosis must be made with caution. In particular, the differential diagnosis with disorders related to autism should be considered. It is not uncommon even today, a diagnosis of depression in the infant or child is placed in error, for a child with infantile autism or other pervasive developmental disorders.
Adolescent Depression
Depression in adolescence is manifested, like that of the child, very differently than adults. Puberty has brought its share of physical changes that adolescence integrate or not, more or less on the psychological level.Always be alert to the risks of acting out suicidal. More than ever, the clinician should not rely on appearances, an arrogant attitude can hide such a profound contempt for oneself and one’s capacity, particularly at school level. Addictive behaviors of all kinds, eating disorders, runaways, verbal abuse and / or physical agent. may be defensive attempts to fight against depression and melancholy.
At the behavioral level it lists these disorders according to DSM and ICD classifications: a mood disorder with boredom, irritability (for the whole entourage), and opposition or even hostility, impulsivity, aggression. Sometimes called hostile depression. The dialogue quickly becomes impossible, replaced by tears. There is also a tendency to inhibition, anhedonia, with divestment of leisure and relationships that were previously invested; somatic complaints: headaches, insomnia, hypersomnia or clinophilia, anorexia or increased appetite contrary, sometimes with binge eating;Anxiety disorders frequently associated with: social phobia, panic attacks, obsessive compulsive disorders intellectuals inability to think (the individual sees things but feels no positive or negative, has no opinion …).
It is sometimes difficult to differentiate between depression and a simple evolutionary moment of adolescence and the use of specialists is recommended. This is even more difficult than the adolescent tends to trivialize the situation, either by shame or by feelings of hopelessness (nobody does) or because he does not perceive his or ill feeling and inner experience. The clinic is led by psychopathologists that differentiates depression from each other and to measure its severity. Proponents of CBT prefer using randomized testing as Beck where you will search what is referred to as a triad. In the following questions, the subject usually responds as follows: * ‘What do you do? Nothing, I’m good for nothing! You look a little news on TV? No it sucks! You know what you want to do later? No …! What do you think? Nothing, I do not know. ‘ Would emphasize that these three responses to this teenager, everything is void, of no value to him, the world and the future.
Only a dialogue conducted with sensitivity and attention by the clinician can help the adolescent to understand what is happening and to overcome. This can be done in the doctor’s office (but do not forget that this age is difficult for the pediatrician who finds it difficult not to see the young person he has in front of him, child he knew but that has changed.) That is also a time when it can be helpful for adolescents to change doctors, this apart from the fact that a psychotherapeutic approach is undertaken or not. Insofar as adolescents may accede enough we can also provide psychotherapy, psychoanalysis or not.Sometimes, in severe cases, psychiatric hospitalization may be necessary and beneficial. Unfortunately, services for adolescents are becoming increasingly rare due to restrictions of any kind which too often deprives adolescents of proper treatment. Do not forget that a teenage crisis underpinned by a depression could also inaugurate positive change and a more integrated psychological reorganization. The adolescent clinic always oscillates between the risk of trivializing that dramatize and is its difficulty and interest.
Depression in the elderly
Depression and Alzheimer’s Disease
A recent study (2008) shows that for Alzheimer’s disease, exposure to natural light reduces symptoms of depression (-19% in the study), and also taking melatonin facilitates sleep (8 min earlier) and extends the sleep of 27 minutes on average). The combination light melatonin also decreased aggressive behavior (- 9%), the phases of agitation and nighttime awakenings.
Perinatal Depression
Pre and postnatal depression are common and yet under-diagnosed. The first pass unnoticed, the mother is ashamed of her condition and often hides his entourage – including obstetrician – who tends to put any signs of depression under the seal of the fatigue of pregnancy. The other is to differentiate from simple baby blues, which occurs most often after a free interval of 2 months and carries an array of typical or masked depression, is the most frequent complications postpartum in approximately 15% deliveries.
Causes of depression
Increasingly, and as for many psychiatric disorders, depression is understood as resulting from the interaction of a range of psychological, biological, social and genetic. This formula is conventionally and who can represent the form of a star:depression is the result of a factor present crisis presents itself as ‘a trigger’ that – it’s a trend – too often holds the attention of the clinician who bank thus neglecting the synchrony diachrony, including the life history of the subject and the interaction of:
Hypotheses about the biological
Every psychological state could correspond to physiological state. We are used to treat this aspect with regard to stress, for example, that we connect to adrenaline. This is part of popular language. Studies have shown the presence of different neurobiological dysfunction in depressed people. Among others, levels of serotonin and norepinephrine (neurotransmitters) are implicated in depression.
A number of biological abnormalities have been found in blood or brain of depressive patients. It is not always clear whether these abnormalities are causes or consequences of the disease, which may explain some failures of drug treatment.However, they open the door to new pharmacological therapies.
Research into the causes of depression have led researchers to examine brain chemistry. In the early fifties, some of the class of neurotransmitter monoamines attracted attention. These neurotransmitters, all derived from an amino acid, included dopamine, norepinephrine and serotonin. We know now that a system malfunction of noradrenaline or serotonin contributes to depression in some individuals, but the neurotransmitters are just beginning to reveal their mysteries and even today we do not yet know all their implications for the behavior human. One hypothesis is that the presynaptic reuptake of monoamines is too high, which creates a lack of these neurotransmitters. It has also been shown that neurotransmitters are destroyed during their passage through enzymes, monoamine oxidase.Norepinephrine is destroyed in a substance that is the dose in urine or MHPG méthoxyhydroxyphénylglycol gold was seen in many depressed urinary excretion of MHPG (from norepinephrine) decreased. The action of this enzyme would be too strong. The hyperactivity of this enzyme has been demonstrated in some depressed by a brain scan study. This would explain the effectiveness of certain treatments previously prescribed type monoamine oxidase inhibitor, commonly known as MAOIs.
Another hypothesis is the presence of an abnormality in brain receptors. This theory suggests an abnormality in the number of postsynaptic receptors. It also relates monoamines neurotransmitters but on a different model. The number of receptors that bind neurotransmitters come after crossing the synapse is not fixed but it changes depending on the quantity to maintain a fairly constant transmission of impulses:
The role of cortisol, a hormone whose production is increased under stress, seems also crucial.The rate is significantly increased in cases of depression, secondary to increased CRH. By cons, drugs targeting the inhibition of its production proved a disappointing effectiveness.
It is sometimes found a deficit of intracerebral BDNF (Brain-derived neurotrophic factor), an enabling factor for the growth of neurons and plasticity of synapses (junctions between neurons). This decrease is however not specific as found in several psychiatric disorders.
Other markers are being studied. Among these include homocysteine and omega-3.
Assumptions about the psychological factors
The biological aspect is not exclusively ‘the cause’ of the first depression. As most experts believe that depression is multi-factorial (overdetermined), all these factors interact with each other. The psycho-dynamic models explain in their own way, sometimes complementary sometimes contradictory mental processes e / or behavioral patterns of depression (cf.behaviorism, psychoanalysis, etc.)..
For specialists from the behaviourism, explains that when people are depressed, they tend to see reality more negatively. In turn, this more negative emotions amplifies depressive. On the other hand, negative interpretations of reality and the depressing emotions influence behavior (leading example of passivity) that in turn have an impact on thoughts and emotions. For psychoanalysts, there are also factors that are often unconscious intrapsychic by examples of processes of mourning, a fear of object loss or other conflicts. Freud in Mourning and Melancholia, Karl Abraham and Melanie Klein, etc.., Opened the field of a deep understanding of depression.
Apart from these views that are important to treatment, all kinds of scales have been established typologies (cf. Ernst Kretschmer) and the predisposing factors, with depression (see for example the profiles of depression Fr . Lelord and C. André).There are several more like those who put forward the ‘rate’ of stress events (death, accident, moving, etc.. Etc.) Classified by the impact they are supposed to have the appearance of a depression. All these scales involve external events on and try and explain the so-called reactive depressions.
Assumptions about the genetic factors
It is recognized that for certain depression hereditary factors play a role in creating the chemical imbalance in the brain when a person is experiencing depression. Although some genes are involved in depression, it does not appear that they inevitably trigger the disease. They would be content to transmit susceptibility to more easily enter a state of depression. Susceptibility when an event outside a particular personality might turn into a real depression. The genetic contribution of depression is approximately one-third (which is less than schizophrenia or bipolar syndrome).This heritability is more important in severe or occurring early. It is also important to realize that regardless the factor that precipitated a person into a depressive state, the final common pathway for depression, so to speak, involves an imbalance of certain neurotransmitters in the brain.
Several genes are being studied. Among these, the presence of a gene polymorphism of the serotonin transporter (5-HTTT) would be significantly associated with the occurrence of a reactive depression to the stress of everyday life.
Assumptions about the social
Separations in early childhood or early childhood often make it more prone to depression in adulthood (cf. studies of Rene Spitz).
A difficult environment (hectic lifestyle, professional concerns and / or family, unemployment, divorce, bereavement, isolation, displacement, relocation) could make it more prone to the appearance and / or maintenance of depression.The importance and quality of support we receive through our interpersonal relationships (relatives, spouses, children, friends …) can protect us against stress and tensions of daily life, and reduce physical and emotional reactions stress, one of which may be depression. On the other hand, the absence of a close relationship, trust may increase the risk of depression.
History of depression
Depression has always existed: Homer spoke in song VI of the Iliad about Bellerophon who suffers the wrath of the gods: Object of hatred for the gods, he wandered alone in the plain Alcion, heart devoured grief, avoiding the footsteps of men. Homer is also the first extols the healing power of a mixture of herbs pharmakon virtues relieving. Hippocratic Aphorisms in writing: When the fear and sadness lingers long, it’s a sad state. Here then appears the ‘black bile’ and the theory of humors which he initiated and which will remain in force until the advent of modern medicine.Galen, rediscovered in the eighteenth century, for example, maintain that this theory also promotes a series of treatments ranging from medical and pharmaceutical cures ‘philosophical’ (entities), religious or even music, etc.. With Pinel and Esquirol primarily assumed the role of the brain is implicated as causes so-called ‘moral’ (today we would say psychological). Essentially an evil psychic calls and psychological remedies, Esquirol (1772-1840) wrote this: The moral medicine (now it looks like psychotherapy), which seeks in the heart of the leading causes of evil, who complains, cries, console , which shares the pain and awakens hope, is often preferable to any other. Ideas evolve much until 1900 but the proposed cure compete imagination. Everything was good for distracting the dark depressed moods!
Psychoanalysts, Sigmund Freud, Karl Abraham and Melanie Klein have allowed the emergence of a processual vision of depression located in the depression as the result of a psychic conflict (oedipal or narcissistic) and not as a passive carrier disease to cure. For Freud it’s sagit resolve the conflict repressed by analyzing strengths, so that the patient finds the freedom ‘to decide for this or that.’
It is also the success of pharmacology who gave depression its present size. Failing to know how to explain it enough thought at least now be able to heal. It is the Swiss psychiatrist Roland Kuhn, psychoanalytic circles close in 1956, discovered the antidepressant effects of imipramine. The Geigy pharmaceutical company initially refused to fund the development, judging, so the market is too narrow depression but views have evolved on this subject. These first antidepressants were mainly prescribed to hospital by psychiatrists for fear of side effects.From the late 1980s, new antidepressants coming on the market with less adverse effects. They are therefore required by all physicians, not just psychiatrists and sometimes below the usual indications. It has been thought that the lesser state of sadness could justify a requirement, however, minimizing side-effects like weight gain and decreased libido. The issue of depression – in fact we should rather speak in the plural – is largely become a matter of pharma market.
The German psychiatrist Hubertus Tellenbach theorized the various aspects of the problem of depression in a comprehensive and advanced on the psychopathological point of view. His book is a reference to the international level. One of his statements was that it was not about to see the melancholy in a bid to strict physico-chemical models.For him disciplines like philosophy (Heidegger in particular), psychology, the contributions of psychoanalysts such as Sigmund Freud and Karl Abraham, psychiatry through the contributions of Kraepelin and Kretschmer are complementary and indispensable to fully understand the phenomenon. Pharmacology does not solve everything, nor the time of the first antidepressant that today!
Definitions
The term covers at least three meanings: it can refer to a symptom, syndrome or disease entity – in the current language disease – manifested by a sustained loss of vital energy (fatigue, lowered self-esteem, pessimism , etc..). The symptoms are similar to what can produce extreme fatigue, but they do not spend the rest. According to Ey, a definition that remains entirely relevant: ‘it’s acting a very complex disease process (…) In any case, whether as a result or as a simple association, it is added to mood disorders two other phenomena: the ‘inhibition’ and the ‘moral pain’. ‘ Inhibition is ‘a kind of braking or slowing of mental processes of ideation, which reduces the field of consciousness and interest, the subject folded on itself and pushes the others to flee and relationships with others. Subjectively, the patient feels a moral fatigue, difficulty thinking, to raise (memory disorders), mental fatigue. (…) The grief expressed in the form of self-deprecation that can become self-blame, self-punishment and guilt. ‘The biological mechanisms, neuropsychological, psychological, sociological depression are constantly interacting and it is not possible today to reduce depression in only one of them even though significant progress has been made in recent years . The most notable of these advances is that doctors and patients now have effective medications (antidepressants) that act on the effects of some depressions but also to achieve its causes.These drugs often cause and also of non-negligible side effects (weight gain, decreased libido) that make the doctor pay attention to the scale ‘cost – benefit’ in the indication and duration of treatment. One must be careful that psychopathology is still sometimes used to distinguish between depression and melancholy, which for the last, is the most serious and most dangerous in terms of suicide risk. Note that depressive disorders often are coupled with physical disorders, pain of undetermined origin, anorexia, etc.. Etc.., We also spoke of masked depression for a variety of physical disorders hiding depression. Depressions can also say with other psychopathology, hysteria, traumatic neurosis, etc..
Nosological entity as to the contours more or less precisely established, the depressions are common, according to statistical studies, reaching almost 20% of each human being to life.The most serious risk of progression of this disease is suicide, especially when depression goes unnoticed and is not supported. Thus, and in France, an estimated 70% of those dying by suicide suffered from depression most often not diagnosed and treated. Depression may occur in infants, children and adolescents (rarely in the same form as in adults), adults and the elderly in whom it is common.
Treatments
We do not treat depression in the same way the infant, child, adolescent, adult or elderly person! For adults, the chapter on treatment is extremely difficult to deal: everything is said, tried and ‘sold’ about the treatment of depression: from walking, exercises, positive thinking, psychoanalysis through the tcc , light therapy, travel, etc.. etc.., to ECT or psychosurgery.The fact that under ‘depression’ are heard a range of disorders does not simplify things and the commercial aspect (antidepressants) relating thereto. We must also deal carefully with statistical research that sometimes – too often – again demonstrating the bias of those who were doing that reliable results and meaningful long term. It is best to first seek assistance from specialists (psychiatrists, psychologists, clinicians) before moving lightly. Basically, it is generally accepted that psychotherapy and antidepressants act at best, often jointly, psychotropic only rarely. It all depends also, of course, and again the patient age, type of depression and their own history as well as any identifiable causes of ‘the’ depression (trauma, childbirth, burnout, etc.)..
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