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Aetiology and pathology of clinical depression

By Premal J. Shah

Depression is fast becoming a substantial public health concern,with the continuing rise in its prevalence. The World Health Organization (WHO) predicts that by 2020, depression will become the second leading cause of DALYs (disability adjusted life-years) lost worldwide, after ischaemic heart disease. About 20 per cent of the population will develop a depressive episode at some point in their lives, with up to 85 per cent of patients having more than one episode. Further, one in 10 patients with depression will commit suicide, and up to 20 per cent of patients with depression will have symptoms for two years or more (chronic depression).1

These startling predictions contrast with the perception of the lay public. Perhaps even more worrying is that the knowledge of health professionals and their attitude towards depression are at odds with the WHO projections. This can be seen in the fact that despite the availability of effective treatments, only a quarter of primary care patients receive adequate pharmacological cover when treatment is initiated. It is crucial that patients receive effective treatments, since suboptimal treatment can be associated with patients developing chronic disease.

It is noteworthy that guidelines and educational programmes have generally not been successful in improving the management of depression, despite there being over 45 separate treatment guidelines for depression in the UK. This suggests that there are major deficiencies in the attitudes of health professionals towards depression.

There is arguably one central belief that is proving to be a major barrier to successful therapy. This is the belief that depression is not a brain disorder but “a problem of the mind” occurring in the context of an understandable cause and thus not within the realm of conventional medical expertise. Such a view has evolved because little is known about the physiology of normal human emotion regulation and also because, like most psychiatric disorders, a quantifiable pathology has been difficult to identify. The term “depression” is a misleading label, being frequently used to denote emotional experiences ranging from normal sadness to a pathological condition. Given this, it is not surprising that pharmacological interventions are seen as an admission of weakness, shame or a psychological crutch that should be used for as short a period as possible.


The feeling of depression, or a pervasive, continually lowered mood is a symptom and can be found in a number of diagnoses, both psychiatric and non-psychiatric.

Panel 1 (p220) provides examples of conditions in which depressed mood can be found. For non-psychiatric conditions, the presence of other symptoms and results from investigative tests will usually indicate the correct primary diagnosis. In a similar vein, attributing a psychiatric cause to a depressed mood requires the presence of other symptoms found in the syndrome, and is not a diagnosis reached by excluding other causes.

Download the attached PDF to read the full article.

Citation: Hospital Pharmacist URI: 10976422

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